Chapter 5.

Mental, Behavioral
and Neurodevelopmental
Disorders (F01–F99)

Chapter-specific Guidelines with

Coding Examples
The chapter-specific guidelines from the ICD-10-CM Official
Guidelines for Coding and Reporting have been provided
below. Along with these guidelines are coding examples,
contained in the shaded boxes, that have been developed to
help illustrate the coding and/or sequencing guidance found
in these guidelines.

a. Pain disorders related to psychological factors

Assign code F45.41, for pain that is exclusively related to
psychological disorders. As indicated by the Excludes 1
note under category G89, a code from category G89
should not be assigned with code F45.41.
Chest pain determined to be persistent somatoform
pain disorder
F45.41 Pain disorder exclusively related to
psychological factors
Explanation: This pain was diagnosed as being
exclusively psychological; therefore, no code from
category G89 is added.
 Code F45.42, Pain disorders with related psychological
factors, should be used with a code from category G89,
Pain, not elsewhere classified, if there is documentation of
a psychological component for a patient with acute or
chronic pain.
See Section I.C.6. Pain
b. Mental and behavioral disorders due to
psychoactive substance use
1) In remission
Selection of codes for “in remission” for categories F10-
F19, Mental and behavioral disorders due to
psychoactive substance use (categories F10-F19 with
-11, -.21) requires the provider’s clinical judgment. The
appropriate codes for “in remission” are assigned only
on the basis of provider documentation (as defined in
the Official Guidelines for Coding and Reporting),
unless otherwise instructed by the classification.
Mild substance use disorders in early or sustained
remission are classified to the appropriate codes for
substance abuse in remission, and moderate or severe
substance use disorders in early or sustained remission
are classified to the appropriate codes for substance
dependence in remission.
Physician documentation indicates the patient is
seen to monitor progress on quitting cigarette
smoking. The problem list indicates mild tobacco use
disorder that is currently in remission.
F17.211 Nicotine dependence, cigarettes, in
remission
Explanation: According to the index, Disorder,
tobacco use, cigarettes (mild) (moderate) (severe),
in remission (early) (sustained) is categorized to
dependence (F17.211). Since the physician clearly
 documents mild cigarette use “disorder” and that
the disorder is in remission, a code for nicotine
dependence “in remission” is appropriate.
2) Psychoactive substance use, abuse and
dependence
When the provider documentation refers to use, abuse
and dependence of the same substance (e.g. alcohol,
opioid, cannabis, etc.), only one code should be
assigned to identify the pattern of use based on the
following hierarchy:
• If both use and abuse are documented, assign only
the code for abuse
• If both abuse and dependence are documented,
assign only the code for dependence
• If use, abuse and dependence are all documented,
assign only the code for dependence
• If both use and dependence are documented, assign
only the code for dependence.
History and physical notes cannabis dependence and
ongoing cannabis abuse
F12.20 Cannabis dependence, uncomplicated
Explanation: In the hierarchy, the dependence code
is used if both abuse and dependence are
documented.

Current problem list indicates daily opioid use with

opioid abuse.
F11.10 Opioid abuse, uncomplicated
Explanation: In the hierarchy, the abuse code is used
if both abuse and use are documented.
3) Psychoactive substance use, unspecified
 As with all other unspecified diagnoses, the codes for
unspecified psychoactive substance use (F10.9-,
F11.9-, F12.9-, F13.9-, F14.9-, F15.9-, F16.9-, F18.9-,
F19.9-) should only be assigned based on provider
documentation and when they meet the definition of a
reportable diagnosis (see Section III, Reporting
Additional Diagnoses). These codes are to be used only
when the psychoactive substance use is associated
with a substance related disorder (chapter 5
disorders such as sexual dysfunction, sleep disorder,
or a mental or behavioral disorder) or medical
condition, and such a relationship is documented by
the provider.
4) Medical conditions due to psychoactive
substance use, abuse and dependence
Medical conditions due to substance use, abuse,
and dependence are not classified as substance-
induced disorders. Assign the diagnosis code for
the medical condition as directed by the
Alphabetical Index along with the appropriate
psychoactive substance use, abuse or
dependence code. For example, for alcoholic
pancreatitis due to alcohol dependence, assign
the appropriate code from subcategory K85.2,
Alcohol induced acute pancreatitis, and the
appropriate code from subcategory F10.2, such
as code F10.20, Alcohol dependence,
uncomplicated. It would not be appropriate to
assign code F10.288, Alcohol dependence with
other alcohol-induced disorder.
5) Blood alcohol level
A code from category Y90, Evidence of alcohol
involvement determined by blood alcohol level,
may be assigned when this information is
documented and the patient’s provider has
 documented a condition classifiable to category
F10, Alcohol related disorders. The blood alcohol
level does not need to be documented by the
patient’s provider in order for it to be coded.

c. Factitious disorder
Factitious disorder imposed on self or Munchausen’s
syndrome is a disorder in which a person falsely reports
or causes his or her own physical or psychological signs
or symptoms. For patients with documented factitious
disorder on self or Munchausen’s syndrome, assign the
appropriate code from subcategory F68.1-, Factitious
disorder imposed on self.
Munchausen’s syndrome by proxy (MSBP) is a disorder in
which a caregiver (perpetrator) falsely reports or causes
an illness or injury in another person (victim) under his or
her care, such as a child, an elderly adult, or a person
who has a disability. The condition is also referred to as
“factitious disorder imposed on another” or “factitious
disorder by proxy.” The perpetrator, not the victim,
receives this diagnosis. Assign code F68.A, Factitious
disorder imposed on another, to the perpetrator’s record.
For the victim of a patient suffering from MSBP, assign the
appropriate code from categories T74, Adult and child
abuse, neglect and other maltreatment, confirmed, or
T76, Adult and child abuse, neglect and other
maltreatment, suspected.
See Section I.C.19.f. Adult and child abuse, neglect and
other maltreatment