Understanding Behavior Change (Behavioral Changes, Altered Behavior) is crucial for accurate clinical documentation and medical coding. This guide provides insights into diagnosing and documenting behavior changes (B) in healthcare settings. Learn about common causes, symptoms, and best practices for recording altered behavior in patient charts for improved patient care and accurate medical coding. Explore resources for healthcare professionals related to behavior change documentation, assessment, and diagnosis codes.
Also known as
Symptoms and signs involving appearance and behavior
Covers abnormal behaviors like restlessness, agitation, and apathy.
Mental disorders due to known physiological conditions
Includes behavioral changes caused by physical illnesses or injuries.
Other specified behavioral change
Used for documented behavior changes not classified elsewhere.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the behavior change due to a physical/mental disorder?
Yes
Is there a documented diagnosis?
No
Is it due to bereavement?
When to use each related code
| Description |
|---|
| Shift in usual actions, demeanor, or habits. |
| Impaired cognitive function affecting memory, thinking. |
| Emotional state characterized by low mood, loss of interest. |
Coding B99 lacks specificity. CDI should query for underlying cause to ensure accurate reimbursement and avoid denials for medical necessity. Impacts quality reporting.
Behavior change may be a symptom. Coding guidelines require coding the underlying etiology, not just the symptom. Risk of inaccurate severity score.
Vague documentation of behavior change leads to coding errors. CDI specialists must clarify onset, duration, and context for proper code assignment. Affects compliance.
Q: How can I differentiate between normal developmental behavior changes and clinically significant behavior changes in pediatric patients requiring intervention?
A: Differentiating between normal developmental behavior changes and those requiring intervention involves a comprehensive assessment considering the child's age, developmental stage, and the specific behaviors exhibited. Transient changes aligned with developmental milestones, such as increased independence during adolescence or temporary regressions during stress, are typically considered normal. However, persistent, pervasive, or severe changes impacting academic performance, social interactions, or daily functioning warrant further investigation. Consider implementing standardized behavior rating scales like the Child Behavior Checklist (CBCL) or the Behavior Assessment System for Children (BASC) to objectively measure and track behaviors. Additionally, exploring the context surrounding the behavior changes, including family dynamics, environmental stressors, and any co-occurring medical or mental health conditions, is crucial. Learn more about evidence-based diagnostic criteria for specific childhood behavioral disorders to guide intervention decisions.
Q: What effective behavior change strategies and interventions are supported by evidence for managing disruptive behavior disorders in school-aged children?
A: Managing disruptive behavior disorders like Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD) requires a multimodal approach incorporating evidence-based strategies. Positive Behavioral Interventions and Supports (PBIS) is a framework widely implemented in school settings that focuses on proactively teaching and reinforcing positive behaviors. Parent Management Training (PMT) programs equip parents with skills to effectively manage challenging behaviors at home. Cognitive Behavioral Therapy (CBT) can help children identify and modify maladaptive thought patterns and develop coping skills. For severe cases, consider implementing a Functional Behavior Assessment (FBA) to identify the underlying causes of the disruptive behavior and develop targeted interventions. Explore how combining these strategies can create a comprehensive and individualized treatment plan for each child.
Patient presents with concerning behavior change, potentially indicative of an underlying medical or psychological condition. The observed behavioral changes include [specific observed behaviors, e.g., increased irritability, social withdrawal, agitation, altered sleep patterns, changes in appetite, decreased motivation, difficulty concentrating, memory problems]. Onset of these behavioral changes was [timeframe, e.g., gradual over the past few months, sudden onset one week ago]. Patient denies [relevant negatives, e.g., substance abuse, recent head trauma]. Family history is significant for [relevant family history, e.g., dementia, depression, anxiety]. Differential diagnosis includes but is not limited to dementia, depression, anxiety disorders, medication side effects, metabolic disorders, and neurological conditions. Assessment includes mental status examination, cognitive testing, and laboratory workup to rule out organic causes. Plan includes [treatment plan, e.g., referral to psychiatry for further evaluation, initiation of medication management for suspected depression, behavioral therapy, further neurological investigation]. Patient education provided regarding behavior modification strategies and follow-up care. Current Procedural Terminology (CPT) codes and International Classification of Diseases (ICD) codes will be assigned based on the final diagnosis and treatment provided. Continued monitoring of behavioral changes and response to treatment is warranted.