Success Codes—Psych Edition


For Clinicians and Organizations


Time for another edition of my wildly popular “Success Codes” series. If you haven’t already, you may want to review my world class, yet humbly simple (yes, really) explanation of RAF scoring—it’ll help you understand some of the shorthand terminology below. It’s the only one on the web written by a PCP who’s been in the trenches blocking and tackling since Medicare Advantage first arrived on the scene 20+ years ago—and done so with incredible results.

That’s probably why it’s so good—and so good for you!  Now let’s get started.



More than any other area, psychiatric codes will make or break your performance.  They’re common, associated with serious costs and easy to miss if you’re not paying attention.


You also can’t count on others to submit the diagnoses accurately.  Oh, they’ll submit’em. But without the appropriate documentation, they’re a clawback waiting to happen.


To increase your revenue retention, document your diagnosis with criteria set forth in the DSM-V (online version here).  The criteria is black and white and will render you bulletproof in an audit.  Just create a macro or a smart phrase for each condition that fits the “2 from column A and 6 from column B” approach and customize it each time for the patient.


Do this even if your insurer or your employer says you don’t have to.  This advice comes from personal experience that was expensive, painful and very hard-run.  I paid the tuition in the school of hard knocks so you don’t have to.


Let’s get to it.


There are a LOT of pysch codes associated with increased capitation.


Fortunately, you only need to know a few and apply them systematically to succeed.


  • Major Depression and RAF 0.4
  • Substance dependence RAF 0.4
    • Codes are substance specific
      • uncomplicated F1x.20
      • in remission F1x.21
      • with intoxication F1x.220
      • in withdrawal F1x.23
  • Substance use with intoxication—not dependent F1x.920 RAF 0.4
    • Codes are substance specific
  • Bipolar Disorders F31.xx RAF 0.4


How often do you see a patient with signs of some sort of drug or alcohol intoxication?  For me, it was a daily occurrence.  Address that elephant in the room and, if they fit the DSM-V criteria for intoxication or dependence, document and submit it.


Serum drug levels alone are sufficient for diagnosis if they reach the intoxication threshold—BUT THEY ARE NOT REQUIRED. Document your observations, your physical findings and your discussion with the patient, that’ll be enough.


Is it good patient care? Yes.


Is it is kind of a pain?  Yes.


Is it worth it for a 40% bump in the patient’s monthly capitation?





Here are some additional pearls:



  • Major Depression

Be aware! Major Depression, single episode, unspecified code F329 carries no risk adjustment.  All others do.

  • Substance Dependence

Similar codes along similar pattern with the same RAF adjustment for amphetamines, cocaine, hallucinogens and inhalants.

For prescription medications such as opioids and amphetamines, the clinician submitting the diagnoses CANNOT be the clinician who’s prescribing them—unless the patient is not taking them as prescribed. If you can document that the patient is not taking them as prescribed, then code away!


uncomplicated F10.20

in remission F10.21

with intoxication F10.220

with withdrawal F10.23


uncomplicated F11.20

in remission F11.21

with intoxication F11.220

with withdrawal F11.23


 uncomplicated F12.10

in remission F12.21

with intoxication F12.220

no withdrawal code for Cannabis


  • Bipolar disorder

Big audit target—Commonly diagnosed by uniformed clinicians without any appropriate documentation.

Use the DSM-V criteria before submitting or risk clawbacks.

That’s really all the codes you need to know.  The key is applying them systematically. Do that and both you and your patient will enjoy amazing success.







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