ICD-10-CM Diagnosis Coding for Neuropsychological Assessment

Objective: This paper summarizes the basic principles of diagnosis coding for neuropsychological evaluation of patients with known or suspected brain injury or disease. Method: The resources forming the basis of this article are the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) and the ICD-10-CM Official Guidelines for Coding and Reporting. Conclusion: Diagnosis codes are used to communicate the specific reason for health care encounters and the conditions treated. All health care providers in all health care settings are mandated to implement ICD-10-CM for coding all health care encounters and transactions. It is the providers of health care services who ultimately are responsible for medical record documentation and diagnosis coding. The neuropsychologist's knowledge base, therefore, should include a basic understanding of the structure of the ICD-10-CM, the conventions and rules for diagnosis coding, and the rules for what constitutes accurate coding.