What Is The Schizophrenia Code? DSM-5 And ICD-11 Codes

Schizophrenia is a complex psychiatric disorder associated with several severe mental health symptoms ranging from cognitive impairment to delusions and hallucinations. The official criteria for diagnosing schizophrenia are outlined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). To understand the condition, exploring the DSM-5 and the medical coding process for diagnosing schizophrenia may be helpful.

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The psychotic, cognitive, and negative symptoms of schizophrenia 

Schizophrenia is a psychiatric disorder that is estimated to affect less than  1% of the population. Schizophrenia, schizoaffective disorder, and other mental disorders with psychotic symptoms disrupt brain function, impacting cognition, memory, perception, and behavior, potentially endangering those experiencing severe symptoms. Schizophrenia spectrum and other psychotic disorders may progress through three distinct stages, including prodromal, active, and residual:

• Prodromal phase: This phase is characterized by subtle symptoms like social withdrawal and anxiety, often overlooked due to their nonspecific nature.

• Active phase: In an active phase episode, intense symptoms like hallucinations and paranoid delusions become prominent, often recognized by others even if the individual doesn't acknowledge them.

• Residual phase: This phase, although not noted in the DSM-5, may follow the active phase with lingering symptoms like reduced emotional expression and withdrawal, potentially leading to relapse.

Despite their unique symptoms, identifying these phases, particularly the prodromal stage, remains challenging, often occurring after the condition progresses to the active phase. Symptoms in this phase tend to become noticeable, although this is not always the case for the person experiencing them. 

Key symptoms of the active phases include:

• Delusions: Persistent false beliefs despite evidence to the contrary.

• Hallucinations: Sensory perceptions of non-existent stimuli.

• Disorganized speech: Difficulty organizing thoughts while speaking.

• Unusual movements or behaviors: Actions that differ from typical behavior.

• Negative symptoms: Reduced facial expression, lack of motivation, or disorganized speech.

These symptoms can lead to perpetual suspicion, paranoia, neglect of hygiene, depression, anxiety, and increased risk of substance use.

If you are struggling with substance use, contact the SAMHSA National Helpline at (800) 662-4357 to receive support and resources. Support is available 24/7.

What is the Diagnostic and Statistical Manual of Mental Disorders?

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) is a tool medical and mental health professionals use to define, diagnose, document, and communicate symptoms of mental health disorders among clients and other care team members. The purpose of the DSM-5 is to ensure consistent and reliable diagnoses. The manual’s detailed descriptions and diagnostic criteria help facilitate communication between patients, clinicians, and health insurance providers. 

While the DSM was established in the United States, the manual is referenced worldwide and aids in the development of medications and other treatment methods for various conditions. Continuously updated, the DSM-5-TR provides revised text, clarifications, and new references. In addition to schizophrenia, the handbook defines conditions like bipolar disorder and autism spectrum disorder (ASD).

Understanding medical codes

Medical coding transforms healthcare diagnoses, procedures, medical services, and equipment into universal medical alphanumeric codes. These diagnosis and procedure codes are established through the DSM-5 and the International Classification of Diseases, 10th Revision (ICD-10), which was recently updated to the ICD-11. The ICD-10 and ICD-11 are diagnostic and procedure coding systems endorsed by the World Health Organization (WHO). 

These diagnosis and procedure codes are taken from medical record documentation, such as transcriptions of physician's notes, laboratory and radiologic results, etc. Medical coding professionals ensure the codes are applied correctly during the medical billing process, which includes abstracting the information from documentation, assigning the appropriate codes, and creating a claim to be paid by insurance carriers.

Medical coding happens every time you see a healthcare provider. The provider reviews your complaint and medical history, assesses what’s wrong and how to treat you, and documents your visit. That documentation details your ongoing record and the provider’s compensation. 

Medical coders translate documentation into standardized codes that tell payers the following:

• Patient's diagnosis

• Medical necessity for treatments, services, or supplies the patient received

• Treatments, services, and supplies provided to the patient

• Any unusual circumstances or medical conditions that affected those treatments and services

Medical coding can be a vital component of the healthcare industry, serving multiple purposes ranging from billing and reimbursement to patient care and research.

What is the schizophrenia code? DSM-5 and ICD-11 Codes

The DSM-5 and ICD-11 work together to diagnose, define, and codify schizophrenia. These handbooks can translate specific types and symptoms of various mental disorders to a uniform, alphanumeric code that allows healthcare and insurance providers to communicate more clearly and easily. 

Schizophrenia code: DSM-5

The DSM-5 code for schizophrenia is “295.9” and can be found under the category “Schizophrenia Spectrum and Other Psychotic Disorders”.

Schizophrenia code: ICD-11

The ICD-11 code for schizophrenia is “6A20” and can be found under the category “Schizophrenia or Other Primary Psychotic Disorders”. The 2024 edition of the ICD-10 annotates “F20.9” as the specific and billable ICD-10-CM code used to indicate a schizophrenia diagnosis. However, codes F01-F99 may also apply to F20.9. The DSM-5 details the meaning of these codes. 

The DSM-5 diagnostic criteria for schizophrenia

Below are the specific schizophrenia DSM-5 criteria.

Criteria A 

For diagnosis, two or more of the following symptoms must be present for a significant portion during one month (or less if successfully treated). At least one of these must be (1), (2), or (3):

1. Delusions

2. Hallucinations

3. Disorganized speech (e.g., frequent derailment or incoherence)

4. Grossly disorganized or catatonic behavior

5. Negative symptoms (i.e., diminished emotional expression or avolition)

Criteria B 

For a significant portion of the time since the onset of the disturbance, the level of functioning in one or more significant areas, such as work, interpersonal relations, or self-care, must be markedly below the level achieved before the onset (or when the onset is in childhood or adolescence, there is failure to achieve the expected level of interpersonal, academic, or occupational functioning).

Criteria C

Continuous signs of disturbance persist for at least six months. This six-month period must include at least one month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or by two or more symptoms listed in Criterion A present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences).

Criteria D 

Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either 1) no major depressive or manic episodes have occurred concurrently with the active-phase symptoms, or 2) if mood episodes have occurred during active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the illness.

Criteria E 

The disturbance is not attributable to the physiological effects of a substance (e.g., substance use or medication) or another medical condition.

Criteria F

If there is a history of autism spectrum disorder or a communication disorder of childhood onset, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations, in addition to the other required symptoms of schizophrenia, are also present for at least one month (or less if successfully treated).

Specifications 

The following course specifiers are only to be used after a one-year duration of the disorder and if they are not in contradiction to the diagnostic course criteria:

• First episode, currently in acute episode: This label is the first manifestation of the disorder meeting the defining diagnostic symptom and time criteria. An acute episode is a period in which the symptom criteria are fulfilled.

• First episode, currently in partial remission: Partial remission is a period during which improvement after a previous episode is maintained and in which the disorder's defining criteria are only partially fulfilled.

• First episode, currently in full remission: Full remission is a period after a previous episode during which no disorder-specific symptoms are present.

• Multiple episodes, currently in acute episode: Multiple episodes may be determined after a minimum of two episodes (i.e., after a first episode, a remission, and a minimum of one relapse).

• Multiple episodes, currently in partial remission

• Multiple episodes, currently in full remission

• Continuous: Symptoms fulfilling the disorder's diagnostic symptom criteria remain for most of the illness course, with subthreshold symptom periods being very brief relative to the overall course.

Catatonia 

Diagnostic providers will also specify if an individual with schizophrenia is showing symptoms of catatonia. In the DSM-5, they may refer to the criteria for catatonia associated with another mental disorder, pp. 119–120, for definition.

Coding note: Providers sometimes use additional code “293.89 (F06.1) catatonia associated with schizophrenia” to indicate the presence of comorbid catatonia.

Severity markers 

Severity is rated by a quantitative assessment of the primary symptoms of psychosis, including delusions, hallucinations, disorganized speech, abnormal psychomotor behavior, and negative symptoms. Each of these symptoms may be rated for its current severity (most severe in the last seven days) on a five-point scale ranging from zero (not present) to four (present and severe). See Clinician-Rated Dimensions of Psychosis Symptom Severity in the chapter “Assessment Measures.”

Note: Diagnosis of schizophrenia can be made without using this severity specifier. Schizophrenia is a complex disorder. While the DSM-5 provides detailed information on the condition, this criterion should be explored with the help of a qualified medical or mental health professional. 

Mental health care for schizophrenia 

With medical treatment, individuals diagnosed with schizophrenia may effectively manage their symptoms. Research suggests that combining medication with non-pharmacological treatments like cognitive-behavioral therapy (CBT) can offer a more comprehensive approach to managing symptoms. 

A treatment plan that combines medications, such as conventional antipsychotics, with supportive services and therapy is often the most successful approach. Through psychotherapy like CBT, people living with schizophrenia can learn to manage difficult situations, develop better social and problem-solving skills, and reduce the severity of symptoms. 

In some cases, people with schizophrenia may struggle to attend in-person therapy appointments due to attainability challenges. In these cases, online platforms like BetterHelp can offer therapy from home, often matching clients with a therapist within 48 hours after signing up. 

Additionally, online therapy may provide affordable and flexible support that is particularly beneficial for those seeking a therapist they can genuinely connect with. While the effectiveness of online treatment for schizophrenia requires further research, studies show that online CBT is equally as effective as in-person therapy for treating other mental health conditions like anxiety and depression, which may be comorbid with schizophrenia. Online therapy can be a helpful option for those with schizophrenia and their caregivers. However, those experiencing acute psychosis may need to seek in-person care.