Psychiatry cheat sheet

Mental Health ICD-10 Cheat Sheet – My Clients Plus

As a therapist, you may find the billing and claims submission process cumbersome. And for good reason: billing is complex due to the requirements of insurance companies that want detailed justification for the services you’re providing. In addition to the CPT services codes that you’ll bill for, you must also include ICD-10 diagnoses codes in your claims. In this post, we explore a bit of background on the ICD-10 and offer a cheat sheet for mental health ICD-10 codes that you can use as a reference.

What is the ICD-10 Exactly?

Before we dive into the specifics of how the ICD-10 is laid out and share the codes applicable to mental health, here’s what you should know about the code set to give you a broader understanding.

“ICD” stands for International Classification of Disease and is the title of the classification tool for medical diagnoses compiled by the World Health Organization (WHO). It was originally designed to help medical professionals worldwide communicate with one another about various diseases in an effort to cooperate in their efforts, particularly in cases of epidemics and pandemics. Now it’s used for a variety of purposes, including insurance billing.

The WHO updates the ICD periodically and the current version is the ICD-10. This is a worldwide reference, so the U.S. has developed its own clinical modification (ICD-10-CM) for use in this country. While the ICD-10-CM is based on the WHO’s ICD-10 set, there are a few unique differences. (Typically, when people in the U.S. refer to the ICD-10, they’re talking about the ICD-10-CM.) The U.S. version has over 70,000 different codes that describe diseases, signs and symptoms, abnormal findings, complaints, and external causes of injury or diseases. These codes are used in the healthcare claims submission process for purposes of reporting and reimbursement — they help provide justification for providing a client with the services you did.

How the ICD-10 Mental Health Codes Are Organized: G, Z, and F Codes

The mental health ICD-10 codes are organized into three primary categories: G, Z, and F.

The G codes comprise diseases of the nervous system. The Z codes describe situations where the client doesn’t have a specific disorder but services are required anyway, such as if a client has a personal history of psychological trauma or if an authority body has requested a general psychiatric examination for someone. The F codes make up the majority of the mental health ICD-10 codes.

ICD-10 Codes for Mental Health Cheat Sheet

While there are many codes that may conceivably be used in healthcare situations, you won’t encounter all of them in your therapy practice. You’re unlikely to encounter the G codes since these are typically dealt with in a medical setting, but we’ve included the ones in this cheat sheet that you may come across. The list also includes the Z codes you’re likely to encounter. Since the F category is the most robust, we’ve included the most common F codes in this list, although you may encounter others that are less common. You can find a complete list of the major F subcategories here.

Common G Codes

G20 (Parkinson’s disease)
G30 (Alzheimer’s disease)
G90 (disorders of autonomic nervous system)

Common Z Codes

Z00. 4 (general psychiatric examination, not elsewhere classified)
Z03.2 (observation for suspected mental and behavioral disorders)
Z04.6 (general psychiatric examination, requested by authority)
Z09.3 (follow-up examination after psychotherapy)
Z13.3 (special screening examination for mental and behavioral disorders)
Z13.4 (special screening examination for certain developmental disorders in childhood)
Z50.4 (psychotherapy, not elsewhere classified)
Z54.3 (convalescence following psychotherapy)
Z63.0 (problems in relationship with spouse or partner)
Z71.1 (person with feared complaint in whom no diagnosis is made)
Z71.9 (counseling, unspecified)
Z81.8 (family history of other mental and behavioral disorders)
Z91.4 (personal history of psychological trauma, not elsewhere classified)

Common F Codes

F41.1 (generalized anxiety disorder)
F43.23 (adjustment disorder with mixed anxiety and depressed mood)
F43. 22 (adjustment disorder with anxiety)
F33.1 (major depressive disorder, recurrent, moderate)
F43.20 (adjustment disorder, unspecified)
F41.9 (anxiety disorder, unspecified)
F43.21 (adjustment disorder with depressed mood)
F43.12 (post-traumatic stress disorder, chronic)
F34.1 (dysthymic disorder)
F43.10 (post-traumatic stress disorder, unspecified)
F32.1 (major depressive disorder, single episode, moderate)
F33.0 (major depressive disorder, recurrent, mild)
F32.9 (major depressive disorder, single episode, unspecified)
F90.2 (attention-deficit hyperactivity disorder, combined type)
F60.9 (personality disorder, unspecified)
F40.228 (other natural environment type phobia)
F43.25 (adjustment disorder w mixed disturb of emotions and conduct)
F06.1 (catatonic disorder due to known physiological condition)
F33.2 (major depressive disorder, recurrent severe without psychotic features)
F41. 0 (panic disorder without agoraphobia)
F90.0 (attention-deficit hyperactivity disorder, predominantly inattentive type)
F32.0 (major depressive disorder, single episode, mild)
F42.2 (mixed obsessional thoughts and acts)
F84.0 (childhood autism)

Use as a Reference, But Understand the Nuances of the Codes

It’s important to note that you shouldn’t rely on the short descriptions of the codes only. Payers can be very particular when it comes to the codes they’re looking for to accompany specific services, and you’ll want to make sure you’re using the right ones. This is especially important as occasionally a therapist will use a code or set of codes that have a higher pay rate than the one they should be using (this practice is called upcoding or unbundling), and payers see this as abuse or fraud. However, with an understanding of the details of each diagnosis, this cheat sheet will serve as a reminder to jog your memory.

Mental Status Exam Cheat Sheet

A mental status exam is an assessment of a patient's cognitive and behavioral functioning. It’s based on the clinician’s observations and the client's subjective descriptions. You might think of a mental status exam as a psychiatrist’s version of a physical exam. Behavioral health professionals use mental status exams to create a picture of how a person looks in the present moment — not all of the time.

Table of Contents

What Are the Components of a Mental Status Exam?
Why Are Mental Status Exams Important?
When Are Mental Status Exams Performed?
Who Uses Mental Status Exams?
How Do I Write a Mental Status Exam?
Mental Status Exam Checklist
Mental Status Exam Example
Claim Your Free Trial of ICANotes

What Are the Components of a Mental Status Exam?

In general, the components of a mental status exam include descriptions of the following:

Appearance
General behavior
Speech and language
Emotions
Thought and perception
Cognition

The exam may also include cognitive testing, depending on a client’s needs.

Why Are Mental Status Exams Important?

In combination with family and personal histories, the mental status exam forms the foundation for a psychiatric diagnosis.Clinicians can also use mental status exams for the following reasons:

To determine if certain issues are improving or getting worse
To identify areas that need attention from a specialist
To offer a snapshot of a client at a specific point in time and provide that information to another provider

When Are Mental Status Exams Performed?

Mental status exams are often performed during the first one or two sessions with a client as part of the initial assessment and when reassessing their symptoms. It should be performed in person and not over the phone due to its visual elements. Mental status exams are especially useful in helping clinicians differentiate between various psychiatric and neurological disorders.

Typically, these exams are used for patients who have chronic, severe, or acute symptoms. A mental status exam aims to capture dysfunction, though you can still use them to confirm ordinary function for clients.

As a behavioral health professional, you may choose to complete regular mental status exams to identify progress or on an as-needed basis throughout the treatment process. Completing a mental status exam at the end of treatment can highlight the differences in a client's presentation and illustrate their growth.

Who Uses Mental Status Exams?

Although mental status exams have been an assessment tool mainly used in clinical psychology, psychiatry, and social work to examine patients with an altered mental status or evolving impairment of cognition, counselors and therapists can also use this type of exam as an informal way to gain information about a client’s cognitive and behavioral functioning. The counselor's findings can help them diagnose and treat a mental health disorder. Mental status exams also provide an excellent source of documentation to support a diagnosis.

How Do I Write a Mental Status Exam?

In private practice, you have the flexibility to create the sections you want to include in your mental status exam. When you are writing your mental status exam, review the typical sections, and identify which ones you believe will be useful to document during your intake assessments with clients. Keep in mind that some sections may be more or less relevant for specific clients.

To determine which portions to include in your mental status exam, consider your current clients. Would this apply to at least half of them? If so, it will likely be useful for you. If not, maybe you don't need to include it every time, and you can add it whenever necessary. You may also want to have an "other" section for topics that may come up during a mental status exam but do not fit in already established sections.

Mental Status Exam Checklist

To help you use a mental status exam as an assessment tool, we've created a cheat sheet. The following checklist is meant to be easy to read, so you can use it as a quick reference. Although you can customize a mental status exam to suit each client, you’ll generally want to focus on the categories in this checklist:

1. Appearance

Appearance includes your observations of how a client looks initially and throughout the assessment. A client's appearance gives you an idea of their functioning level, their history, and symptoms they're experiencing. Always look for signs of self-neglect and note anything unusual.

Hygiene and Grooming

Would you describe your client's hygiene and grooming as:

Clean
Neat
Shaven
Body odor
Disheveled

Dress

Is your client's clothing:

Casual
Immaculate
Neat
Business
Fashionable
Bizarre
Inappropriate
Dirty
Stained
Ragged

Makeup

Is your client's makeup:

Appropriate
Garish
Bizarre
No makeup

Distinguishing Features

Does your client have any distinguishing features, such as:

Tattoos
Piercings
Scars

Apparent Age

Does your client appear:

Older than their stated age
Younger than their stated age

Habitus

Is your client's habitus:

Normal
Underweight
Overweight
Obese

Facial Expressions

Does your client appear:

Calm
Sad
Anxious
Disgusted
Angry
Perplexed

2.

General Behavior

Describe how your client moves and behaves physically during the assessment. Always note if they are being hostile, uncooperative or have inappropriate impulses.

Eye Contact

Isyour client's eye contact:

Appropriate
Decreased
Heightened
Avoidant

Motor Activity

Does your client display:

Normal activity
Decreased activity
Restlessness
Tension
Agitation

Gait

Does your client:

Seem unsteady
Limp
Shuffle
Use a cane, crutches or another device

Orofacial Dyskinesia

Does your client display unusual movements in the jaw, face or tongue, such as:

Grimacing
Tongue writhing
Lip smacking
Lip pursing
Chewing

Cooperativeness and Attitude

Doesyour client exhibit an appropriate level of cooperation, or are they:

Evasive
Guarded
Playful
Ingratiating
Passive
Sullen
Withdrawn
Manipulative
Demanding
Hostile
Overly friendly
Relaxed
Open
Shy
Candid
Suspicious

Movements

Does your client display any unusual or repetitive movements, such as:

Tics
Twitches
Tremor
Mannerisms
Stereotypies
Posturing

3.

Speech and Language

Consider how your client speaks and uses language. The amount a client speaks and how they talk can indicate a mental health issue such as depression or anxiety or a neurocognitive disorder.

General

Does your client speak clearly or have an:

Accent
Stutter
Lisp

Rate

Is your client's rate of speech:

Normal
Slow
Fast
Delayed onset

Rhythm

Is your client's speech:

Articulate
Slurred
Monotone
Dysarthric

Volume

Is your client's speech:

Soft
Loud
Mute

Content

Is your client:

Loquacious
Fluent
Impoverished

4. Emotions

Try to determine your client's emotional state by asking them how they feel and observing their facial expressions and body language.

Mood

Does your client say they feel:

Depressed
Sad
Angry
Irritable
Good
Fantastic

Affect

Does your client seem to be:

Euthymic
Depressed
Irritable
Angry
Elated
Euphoric
Anxious

Range

Is your client's affect range:

Broad: The client shows a normal range of emotions.
Restricted: Theclient seems limited in expressing emotions.
Flat: The client does not show any change in mood.
Labile: The client's mood changes rapidly.
Anhedonic: The client seems incapable of a pleasurable response.

Congruency

Is your client's affect:

Congruent to their mood
Incongruent to their mood

5. Thought and Perception

Consider how your client's thoughts flow and connect and whether your client has a normal, linear thought process or if they go off-topic or make disorganized associations. Also, listen to what your client focuses on and find out if they're experiencing hallucinations. Always note hallucinations or the presence of delusions, and take appropriate action if a client expresses plans to carry out suicidal or homicidal ideation.

Thought Process

Would you describe your client's thought process as:

Goal-directed: The client answers your questions and does not move onto other related topics.
Impoverished: The client displays slow thinking and does not share many ideas.
Rapid: The client expresses racing thoughts and rapid thinking.
Illogical: The client does not make sense when they speak.
Incoherent: The client's speech is disorganized, and there is no meaning to what they're saying.
Distractible: The client cannot stay focused.
Blocking: The client's thoughts are interrupted.
Circumstantial: The client provides unnecessary detail but gets to the point eventually.
Perseverative: The client shows a repetition of words, ideas or phrases.
Tangential: The client moves from one related thought to the next but never reaches the point.
Loose: The client shifts illogically between unrelated topics.
Flight of ideas: The client quickly jumps from one idea to the next.
Word salad: The client speaks words randomly.

Thought Content

Do your client's thoughts consist of:

Suicidal ideation
Homicidal ideation
Grandiose, somatic, paranoid or other delusions
Distortions
Obsessions
Worries
Compulsions
Phobias
Ruminations

Perception

Is your client experiencing:

No hallucinations
Auditory hallucinations
Visual hallucinations
Tactile hallucinations
Olfactory hallucinations
Illusions
Derealization, or feeling detached from the surroundings
Depersonalization, or feeling separated from him- or herself

6. Cognition

When evaluating a client's cognition, clinicians commonly assess the person's alertness or level of consciousness, orientation, attention, concentration and memory. If your client shows symptoms of a neurocognitive disorder, consider using additional tools such as the Mini-Mental State Examination or the Montreal Cognitive Assessment.

Alertness

Is your client:

Alert
Lethargic
Obtunded
In a stupor
Comatose

Orientation

Does your client know:

Their name
Their current location
The date
The time

Memory

To test your client's memory, you might ask them to do the following:

Repeat three words immediately and again in five minutes.
Sign their name while answering unrelated questions.
Tell you their birthday, where they were born and their parents' names.

Does your client display:

No impairment
Short-term impairment
Long-term impairment

Attention

Does your client's attention seem:

Normal
Distracted

Insight

Describe your client's insight or their awareness of their situation or condition. Start by answering the following questions:

How well does your client understand the reasons for their behavior?
How well does your client appreciate how they contribute to a problem?
Does your client recognize or acknowledge the severity of an issue?
What do they perceive is the best way to address a problem?

Is your client's insight:

Good
Fair
Poor

Judgment

Consider if your client anticipates the consequences of their behavior and makes decisions to safeguard their well-being and that of others. Is their judgment:

Good
Fair
Poor

Impulse Control

Does your client show:

Normal impulse control
Impaired impulse control

Motivation

Would you describe your client's motivation level as:

Good
Fair
Poor

Reliability

Consider your client's reliability and accuracy as they share details about their situation. Do you consider your client to be:

Reliable
Unreliable

7. Environment

If part of your mental status exam includes assessing the client's living environment, you may want to describe their surroundings. Ask yourself the following:

Have they made odd decisions, such as blocking doors or windows with furniture?
Are there unusual decorations or wires that lead nowhere?
Are they using any household objects inappropriately?
Is their home extremely cluttered or dirty?
Do they collect junk or garbage?

Mental Status Exam Example

The following is a brief example of a mental status exam:

Appearance: The client is slouched and disheveled.
General behavior:The client is uncooperative and has poor eye contact.
Speech:The client speaks fast and soft.
Emotions:The client states he feels "depressed and anxious."
Thinking process: The client is incoherent and disorganized.
Cognition: The client is focused and alert, and he performed well on working memory tests.
Insight: The client displays poor insight.
Judgment: The client shows fair judgment.
Reliability: The client is unreliable because he gave false impressions of himself.

Claim Your Free Trial of ICANotes

At ICANotes, we offer behavioral health electronic health record (EHR) software to reduce documentation time and improve compliance. Our EHR is the most clinically robust software for behavioral health professionals and comes with preconfigured templates for every setting and discipline. With our EHR, you can create:

Discharge summaries
Group therapy notes
Initial assessments
Progress notes
Treatment plans

ICANotes is ready right out of the box and can make behavioral health documentation comprehensive, quick and sophisticated enough to meet even the most stringent standards. You can effectively use ICANotes with little training. It's highly intuitive with a clinically logical workflow because its designers were clinicians with a thorough understanding of behavioral health.

ICANotes is the EHR software that thinks like a clinician. If you are a behavioral health clinician working in a residential setting or private practice, claim your free trial of ICANotes to aid with documentation.

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Cheat sheets on psychiatry and narcology

Subject and tasks of psychiatry

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The direction of modern psychiatry

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Out-of-hospital care for the mentally ill

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Rights of mentally ill people

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The concept of nosology

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Perception is the initial stage of higher nervous activity. Through the perception of external and internal...
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Hallucinations

Hallucinations are a disorder of perception in the form of images and ideas that arise without real information...
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Classification of hallucinations

True hallucinations - the patient perceives hallucinatory images as part of the real world, containing. ..
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Syndromes of perceptual disorders

Hallucinosis is a psychopathological syndrome, the leading disorder of which are hallucinations. Gal...
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Mental automatism, depersonalization, derealization

Mental automatism - alienation of the patient's own mental processes and motor acts ...
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Thought disorders

Accelerated pace (tachyphrenia) – thinking is superficial, thoughts flow quickly, easily shift...
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Disorders of the semantic content of the associative process Overvalued ideas are thoughts that are closely fused with the personality of the patient, determining his behavior, having ...
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Mixed delusions

Brad staging. The patients are convinced that those around them are putting on a performance especially for them....
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Memory. Memory classification

Memory is a cognitive (gnostic) function that allows to accumulate perceived information. ..
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Pathology of memory

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Pathology of the intellect

Intellect is a set of human cognitive abilities, the desire to acquire new knowledge....
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Dementia

Dementia is an acquired form of dementia. Dementia, unlike oligophrenia, is always progradient, although...
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Speech disorders

Tachyphasia - accelerated speech, can be manifested by verbosity or interspersed with proverbs, kalambu ...
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Emotional disorders (affective disorders)

Emotions are called sensual reactions (affect) of a person to objects and phenomena of the surrounding world, they...
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Depressive states

Depression is a condition accompanied by an affect of melancholy (hypothymia), mental retardation and decreased...
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Classification of depressions

Somatized (masked, larvated) depression. The leader is the somato-vegetative kom...
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Disorders of will and attention

Will is a purposeful human activity, the ability to set goals. Big sign...
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Motility disorders (psychomotor disorders)

Movement disorders (psychomotor disorders) include hypokinesias, dyskinesias and gi...
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Motor excitation

Hyperkinesias include various violent automatic movements due to involuntary...
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Desire disorders

Attraction is a need that arises as an unconscious desire for something. Disorders of inclinations ...
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Perversion of the instinct to preserve (continue) the genus

Hypoeroticism (hyposexuality) - weakening, lowering sexual desire. Observed in asthenia,...
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Disorders of consciousness

Consciousness is a set of knowledge and ideas of a person about the world around him and about himself. Violations...
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Delirium

Delirium is a pronounced disorder of subject orientation with the preservation of personal orientation. The prod...
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Change of consciousness

Oneiroid (schizophrenic delirium) is a change in consciousness with an influx of fantastic notions, which...
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Asthenic syndrome (asthenia)

It is observed in neurasthenia, somatic diseases, mild variants of exogenous organic races...
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Hysterical syndrome

The clinic of hysterical syndrome is characterized by a variety and variability of symptoms. Always in that...
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Manic-depressive syndrome

Depressive syndrome is manifested by a triad of obligate symptoms: worsening of mood, mental...
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Convulsive paroxysms

Paroxysms (seizures) - suddenly developing, short-term (up to several seconds, less often up to several ...
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Non-convulsive paroxysms

Absences (absence - "absence") - a short-term loss of consciousness, sometimes accompanied by a fall . ..
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Negative (deficiency) syndromes

Negative syndromes are persistent or reversible personality changes in the form of a decrease, defect, or...
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Premorbid personality types

The hyperthymic personality type is distinguished, as a rule, by an elevated mood, high vitality...
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Personality disorders (psychopathies) – pathological characters, may be constitutional, inherited...
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Personality disorders (schizoid, unstable, hysterical, excitable, epileptoid psychopathy)

Schizoid psychopathy is distinguished by the following personality traits: inability to experience pleasure...
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Affective mood disorders

Mood - prevailing for a certain period and influencing all mental activity ...
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Volitional disorders in schizophrenia

For patients with schizophrenia, pathology of volitional functions is typical. They are especially often detected in varying degrees...
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Behavior in schizophrenia

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Non-psychotic productive disorders, classification of schizophrenia

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Malignant schizophrenia

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Sluggish schizophrenia Low-progressive (sluggish) schizophrenia. Sluggish schizophrenia accounts for 17 to 35% of all cases...
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Fur-like form of schizophrenia, special forms of schizophrenia

Attack-like progredient (fur-like) schizophrenia. Coat-like schizophrenia is the most common medium...
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Biological therapy for schizophrenia

biological therapy. The leading place in the biological treatment of schizophrenia belongs to the psychopharmacoter...
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Psychotherapy of schizophrenia

Treatment and rehabilitation. In the treatment of patients with schizophrenia, almost all methods of biological...
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Alcoholism is a chronic disease that develops as a result of prolonged alcohol abuse ...
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Stages of alcoholism (stages I, II, true binges)

The first stage (the stage of mental dependence). The main among the initial signs is pathology...
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Stages of alcoholism (false binges, stage III)

False binges appear at stage II of alcoholism and arise as a result of socio-psychological...
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Drug addiction and substance abuse, opium addiction

A drug is a narcotic drug included in the official state list due to social . ..
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Development and stages of drug addiction

At the first stage, addiction develops quite quickly: it is enough to repeat injections 5 times...
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Cannabinoid addiction

Most often they smoke hashish, marijuana, "plan" - a dried and compressed substance that appears on the surface ...
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Ephedrone and pervitin addiction

Ephedron is manufactured in illicit laboratories from medicines containing ephedrine. Derivative primary ...
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Psychiatry ticket answers

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