22 - Other Conditions That May Be a Focus of Clini

Other Conditions That May Be a Focus of Clinical Attention

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Other Conditions That May Be a Focus of Clinical Attention This chapter includes conditions and psychosocial or environmental problems that may be a focus of clinical attention or otherwise affect the diagnosis, course, prognosis, or treatment of an individual’s mental disorder. These conditions are presented with their corresponding codes from ICD-10-CM (usually Z codes). A condition or problem in this chapter may be coded 1) if it is a reason for the current visit; 2) if it helps to explain the need for a test, procedure, or treatment; 3) if it plays a role in the initiation or exacerbation of a mental disorder; or 4) if it constitutes a problem that should be considered in the overall management plan. The conditions and problems listed in this chapter are not mental disorders. Their inclusion in DSM-5-TR is meant to draw attention to the scope of additional issues that may be encountered in routine clinical practice and to provide a systematic listing that may be useful to clinicians in documenting these issues. For quick reference to all codes in this section, see the DSM-5-TR Classification. Conditions and problems that may be a focus of clinical attention are listed in the subsequent text as follows:

1. Suicidal behavior (potentially self-injurious behavior with at least some intent to die) and nonsuicidal self-injury (intentional self-inflicted damage to the body in the absence of suicidal intent).

2. Abuse and neglect (e.g., child and adult maltreatment and neglect problems, including physical abuse, sexual abuse, neglect, and psychological abuse).

3. Relational problems (e.g., parent-child relational problem, sibling relational problem, relationship distress with spouse or intimate partner, disruption by separation or divorce).

4. Educational problems (e.g., illiteracy or low-level literacy, schooling unavailable or unattainable, failed school examinations, underachievement in school).

5. Occupational problems (e.g., unemployment, change of job, threat of job loss, stressful work schedule, discord with boss and workmates).

6. Housing problems (e.g., homelessness; inadequate housing; discord with neighbor, lodger, or landlord).

7. Economic problems (e.g., lack of adequate food or safe drinking water, extreme poverty, low income).

8. Problems related to the social environment (e.g., problem related to living alone, acculturation difficulty, social exclusion or rejection).

9. Problems related to interaction with the legal system (e.g., conviction in criminal proceedings, imprisonment or other incarceration, problems related to release from prison, problems related to other legal circumstances).

10. Problems related to other psychosocial, personal, and environmental circumstances (e.g., problems related to unwanted pregnancy, victim of crime, victim of terrorism).

Problems related to access to medical and other health care (e.g., unavailability or inaccessibility of health care facilities). 2. Circumstances of personal history (e.g., personal history of psychological trauma, military deployment). 3. Other health service encounters for counseling and medical advice (e.g., sex counseling, other counseling or consultation). 4. Additional conditions or problems that may be a focus of clinical attention (e.g., wandering associated with a mental disorder, uncomplicated bereavement, phase of life problem). Suicidal Behavior and Nonsuicidal Self-Injury Coding Note for ICD-10-CM Suicidal Behavior For T codes only, the 6th character should be coded as follows: A (initial encounter)—Use while the individual is receiving active treatment for the condition (e.g., emergency department encounter, evaluation and treatment by a new clinician); or D (subsequent encounter)—Use for encounters after the individual has received active treatment for the condition and when he or she is receiving routine care for the condition during the healing or recovery phase (e.g., medication adjustment, other aftercare and follow-up visits). Suicidal Behavior This category may be used for individuals who have engaged in potentially self-injurious behavior with at least some intent to die as a result of the act. Evidence of intent to end one’s life can be explicit or inferred from the behavior or circumstances. A suicide attempt may or may not result in actual self-injury. If the individual is dissuaded by another person or changes his or her mind before initiating the behavior, this category does not apply. Current Suicidal Behavior T14.91A Initial encounter: If suicidal behavior is part of the initial encounter with the clinical presentation T14.91D Subsequent encounter: If suicidal behavior is part of subsequent encounters with the clinical presentation Z91.51 History of Suicidal Behavior If suicidal behavior has occurred during the individual’s lifetime Nonsuicidal Self-Injury This category may be used for individuals who have engaged in intentional self-inflicted damage

to their body of a sort likely to induce bleeding, bruising, or pain (e.g., cutting, burning, stabbing, hitting, excessive rubbing) in the absence of suicidal intent. R45.88 Current Nonsuicidal Self-Injury If nonsuicidal self-injurious behavior is part of the clinical presentation Z91.52 History of Nonsuicidal Self-Injury If nonsuicidal self-injurious behavior has occurred during the individual’s lifetime Abuse and Neglect Maltreatment by a family member (e.g., caregiver, intimate adult partner) or by a nonrelative can be the area of current clinical focus, or such maltreatment can be an important factor in the assessment and treatment of individuals with mental disorders or other medical conditions. Because of the legal implications of abuse and neglect, care should be used in assessing these conditions and assigning these codes. Having a past history of abuse or neglect can influence diagnosis and treatment response in a number of mental disorders, and may also be noted along with the diagnosis. For the following categories, in addition to listings of the confirmed or suspected event of abuse or neglect, other codes are provided for use if the current clinical encounter is to provide mental health services to either the victim or the perpetrator of the abuse or neglect. A separate code is also provided for designating a past history of abuse or neglect. Coding Note for ICD-10-CM Abuse and Neglect Conditions For T codes only, the 7th character should be coded as follows: A (initial encounter)—Use while the individual is receiving active treatment for the condition (e.g., surgical treatment, emergency department encounter, evaluation and treatment by a new clinician); or D (subsequent encounter)—Use for encounters after the individual has received active treatment for the condition and when he or she is receiving routine care for the condition during the healing or recovery phase (e.g., cast change or removal, removal of external or internal fixation device, medication adjustment, other aftercare and follow-up visits). Child Maltreatment and Neglect Problems Child Physical Abuse This category may be used when physical abuse of a child is a focus of clinical attention. Child physical abuse is nonaccidental physical injury to a child—ranging from minor bruises to severe fractures or death—occurring as a result of punching, beating, kicking, biting, shaking, throwing, stabbing, choking, hitting (with a hand, stick, strap, or other object), burning, or any other method that is inflicted by a parent, caregiver, or other individual who has responsibility for the child. Such injury is considered abuse regardless of whether the caregiver intended to hurt the child. Physical discipline, such as spanking or paddling, is not considered abuse as long as it is

reasonable and causes no bodily injury to the child. Child Physical Abuse, Confirmed T74.12XA Initial encounter T74.12XD Subsequent encounter Child Physical Abuse, Suspected T76.12XA Initial encounter T76.12XD Subsequent encounter Other Circumstances Related to Child Physical Abuse Z69.010 Encounter for mental health services for victim of child physical abuse by parent Z69.020 Encounter for mental health services for victim of nonparental child physical abuse Z62.810 Personal history (past history) of physical abuse in childhood Z69.011 Encounter for mental health services for perpetrator of parental child physical abuse Z69.021  Encounter for mental health services for perpetrator of nonparental child physical abuse Child Sexual Abuse This category may be used when sexual abuse of a child is a focus of clinical attention. Child sexual abuse encompasses any sexual act involving a child that is intended to provide sexual gratification to a parent, caregiver, or other individual who has responsibility for the child. Sexual abuse includes activities such as fondling a child’s genitals, penetration, incest, rape, sodomy, and indecent exposure. Sexual abuse also includes noncontact exploitation of a child by a parent or caregiver—for example, forcing, tricking, enticing, threatening, or pressuring a child to participate in acts for the sexual gratification of others, without direct physical contact between child and abuser. Child Sexual Abuse, Confirmed T74.22XA Initial encounter T74.22XD Subsequent encounter Child Sexual Abuse, Suspected T76.22XA Initial encounter T76.22XD Subsequent encounter Other Circumstances Related to Child Sexual Abuse

Z69.010 Encounter for mental health services for victim of child sexual abuse by parent Z69.020 Encounter for mental health services for victim of nonparental child sexual abuse Z62.810 Personal history (past history) of sexual abuse in childhood Z69.011 Encounter for mental health services for perpetrator of parental child sexual abuse Z69.021 Encounter for mental health services for perpetrator of nonparental child sexual abuse Child Neglect This category may be used when child neglect is a focus of clinical attention. Child neglect is defined as any confirmed or suspected egregious act or omission by a child’s parent or other caregiver that deprives the child of basic age-appropriate needs and thereby results, or has reasonable potential to result, in physical or psychological harm to the child. Child neglect encompasses abandonment; lack of appropriate supervision; failure to attend to necessary emotional or psychological needs; and failure to provide necessary education, medical care, nourishment, shelter, and/or clothing. Child Neglect, Confirmed T74.02XA Initial encounter T74.02XD Subsequent encounter Child Neglect, Suspected T76.02XA Initial encounter T76.02XD Subsequent encounter Other Circumstances Related to Child Neglect Z69.010 Encounter for mental health services for victim of child neglect by parent Z69.020 Encounter for mental health services for victim of nonparental child neglect Z62.812 Personal history (past history) of neglect in childhood Z69.011 Encounter for mental health services for perpetrator of parental child neglect Z69.021 Encounter for mental health services for perpetrator of nonparental child neglect Child Psychological Abuse This category may be used when psychological abuse of a child is a focus of clinical attention. Child psychological abuse is nonaccidental verbal or symbolic acts by a child’s parent or caregiver that result, or have reasonable potential to result, in significant psychological harm to the child. (Physical and sexual abusive acts are not included in this category.) Examples of psychological abuse of a child include berating, disparaging, or humiliating the child; threatening the child; harming/abandoning—or indicating that the alleged offender will harm/abandon— people or things that the child cares about; confining the child (as by tying a child’s arms or legs

together or binding a child to furniture or another object, or confining a child to a small enclosed area [e.g., a closet]); egregious scapegoating of the child; coercing the child to inflict pain on himself or herself; and disciplining the child excessively (i.e., at an extremely high frequency or duration, even if not at a level of physical abuse) through physical or nonphysical means. Child Psychological Abuse, Confirmed T74.32XA Initial encounter T74.32XD Subsequent encounter Child Psychological Abuse, Suspected T76.32XA Initial encounter T76.32XD Subsequent encounter Other Circumstances Related to Child Psychological Abuse Z69.010 Encounter for mental health services for victim of child psychological abuse by parent Z69.020 Encounter for mental health services for victim of nonparental child psychological abuse Z62.811 Personal history (past history) of psychological abuse in childhood Z69.011 Encounter for mental health services for perpetrator of parental child psychological abuse Z69.021 Encounter for mental health services for perpetrator of nonparental child psychological abuse Adult Maltreatment and Neglect Problems Spouse or Partner Violence, Physical This category may be used when spouse or partner physical violence is a focus of clinical attention. Spouse or partner physical violence is nonaccidental acts of physical force that result, or have reasonable potential to result, in physical harm to an intimate partner or that evoke significant fear in the partner. Nonaccidental acts of physical force include shoving, slapping, hair pulling, pinching, restraining, shaking, throwing, biting, kicking, hitting with the fist or an object, burning, poisoning, applying force to the throat, cutting off the air supply, holding the head under water, and using a weapon. Acts for the purpose of physically protecting oneself or one’s partner are excluded. Spouse or Partner Violence, Physical, Confirmed T74.11XA Initial encounter T74.11XD Subsequent encounter

Spouse or Partner Violence, Physical, Suspected T76.11XA Initial encounter T76.11XD Subsequent encounter Other Circumstances Related to Spouse or Partner Violence, Physical Z69.11 Encounter for mental health services for victim of spouse or partner violence, physical Z91.410 Personal history (past history) of spouse or partner violence, physical Z69.12 Encounter for mental health services for perpetrator of spouse or partner violence, physical Spouse or Partner Violence, Sexual This category may be used when spouse or partner sexual violence is a focus of clinical attention. Spouse or partner sexual violence involves the use of physical force or psychological coercion to compel the partner to engage in a sexual act against his or her will, whether or not the act is completed. Also included in this category are sexual acts with an intimate partner who is unable to consent. Spouse or Partner Violence, Sexual, Confirmed T74.21XA Initial encounter T74.21XD Subsequent encounter Spouse or Partner Violence, Sexual, Suspected T76.21XA Initial encounter T76.21XD Subsequent encounter Other Circumstances Related to Spouse or Partner Violence, Sexual Z69.81 Encounter for mental health services for victim of spouse or partner violence, sexual Z91.410 Personal history (past history) of spouse or partner violence, sexual Z69.12 Encounter for mental health services for perpetrator of spouse or partner violence, sexual Spouse or Partner Neglect This category may be used when spouse or partner neglect is a focus of clinical attention. Spouse or partner neglect is any egregious act or omission by one partner that deprives a dependent partner of basic needs and thereby results, or has reasonable potential to result, in physical or psychological harm to the dependent partner. This category may be used in the context of relationships in which one partner is extremely dependent on the other partner for care or for assistance in navigating ordinary daily activities—for example, a partner who is incapable of self-care because of substantial physical, psychological/intellectual, or cultural limitations (e.g., inability to communicate with others and manage everyday activities as a result of living in a foreign culture).

Spouse or Partner Neglect, Confirmed T74.01XA Initial encounter T74.01XD Subsequent encounter Spouse or Partner Neglect, Suspected T76.01XA Initial encounter T76.01XD Subsequent encounter Other Circumstances Related to Spouse or Partner Neglect Z69.11 Encounter for mental health services for victim of spouse or partner neglect Z91.412 Personal history (past history) of spouse or partner neglect Z69.12 Encounter for mental health services for perpetrator of spouse or partner neglect Spouse or Partner Abuse, Psychological This category may be used when spouse or partner psychological abuse is a focus of clinical attention. Spouse or partner psychological abuse encompasses nonaccidental verbal or symbolic acts by one partner that result, or have reasonable potential to result, in significant harm to the other partner. Acts of psychological abuse include berating or humiliating the victim; interrogating the victim; restricting the victim’s ability to come and go freely; obstructing the victim’s access to assistance (e.g., law enforcement; legal, protective, or medical resources); threatening the victim with physical harm or sexual assault; harming, or threatening to harm, people or things that the victim cares about; unwarranted restriction of the victim’s access to or use of economic resources; isolating the victim from family, friends, or social support resources; stalking the victim; and trying to make the victim question his or her sanity (“gaslighting”). Spouse or Partner Abuse, Psychological, Confirmed T74.31XA Initial encounter T74.31XD Subsequent encounter Spouse or Partner Abuse, Psychological, Suspected T76.31XA Initial encounter T76.31XD Subsequent encounter Other Circumstances Related to Spouse or Partner Abuse, Psychological Z69.11 Encounter for mental health services for victim of spouse or partner psychological abuse Z91.411 Personal history (past history) of spouse or partner psychological abuse

Z69.12 Encounter for mental health services for perpetrator of spouse or partner psychological abuse Adult Abuse by Nonspouse or Nonpartner This category may be used when the abuse of an adult by another adult who is not an intimate partner is a focus of clinical attention. Such maltreatment may involve acts of physical, sexual, or emotional abuse. Examples of adult abuse include nonaccidental acts of physical force (e.g., pushing/shoving, scratching, slapping, throwing something that could hurt, punching, biting) that have resulted—or have reasonable potential to result—in physical harm or have caused significant fear; forced or coerced sexual acts; and verbal or symbolic acts with the potential to cause psychological harm (e.g., berating or humiliating the person; interrogating the person; restricting the person’s ability to come and go freely; obstructing the person’s access to assistance; threatening the person; harming or threatening to harm people or things that the person cares about; restricting the person’s access to or use of economic resources; isolating the person from family, friends, or social support resources; stalking the person; trying to make the person think that he or she is crazy). Acts for the purpose of physically protecting oneself or the other person are excluded. Adult Physical Abuse by Nonspouse or Nonpartner, Confirmed T74.11XA Initial encounter T74.11XD Subsequent encounter Adult Physical Abuse by Nonspouse or Nonpartner, Suspected T76.11XA Initial encounter T76.11XD Subsequent encounter Adult Sexual Abuse by Nonspouse or Nonpartner, Confirmed T74.21XA Initial encounter T74.21XD Subsequent encounter Adult Sexual Abuse by Nonspouse or Nonpartner, Suspected T76.21XA Initial encounter T76.21XD Subsequent encounter Adult Psychological Abuse by Nonspouse or Nonpartner, Confirmed T74.31XA Initial encounter T74.31XD Subsequent encounter Adult Psychological Abuse by Nonspouse or Nonpartner, Suspected

T76.31XA Initial encounter T76.31XD Subsequent encounter Other Circumstances Related to Adult Abuse by Nonspouse or Nonpartner Z69.81 Encounter for mental health services for victim of nonspousal or nonpartner adult abuse Z69.82 Encounter for mental health services for perpetrator of nonspousal or nonpartner adult abuse Relational Problems Key relationships, especially intimate adult partner relationships and parent/caregiver-child relationships, have a significant impact on the health of the individuals in these relationships. These relationships can be health promoting and protective, neutral, or detrimental to health outcomes. In the extreme, these close relationships can be associated with maltreatment or neglect, which has significant medical and psychological consequences for the affected individual. A relational problem may come to clinical attention either as the reason that the individual seeks health care or as a problem that affects the course, prognosis, or treatment of the individual’s mental disorder or other medical condition. Parent-Child Relational Problem Z62.820 Parent–Biological Child Z62.821 Parent–Adopted Child Z62.822 Parent–Foster Child Z62.898 Other Caregiver–Child For this category, the term parent is used to refer to one of the child’s primary caregivers, who may be a biological, adoptive, or foster parent or may be another relative (such as a grandparent) who fulfills a parental role for the child. This category may be used when the main focus of clinical attention is to address the quality of the parent-child relationship or when the quality of the parent-child relationship is affecting the course, prognosis, or treatment of a mental disorder or other medical condition. Typically, the parent-child relational problem is associated with impaired functioning in behavioral, cognitive, or affective domains. Examples of behavioral problems include inadequate parental control, supervision, and involvement with the child; parental overprotection; excessive parental pressure; arguments that escalate to threats of physical violence; and avoidance without resolution of problems. Cognitive problems may include negative attributions of the other’s intentions, hostility toward or scapegoating of the other, and unwarranted feelings of estrangement. Affective problems may include feelings of sadness, apathy, or anger about the other individual in the relationship. Clinicians should take into account the developmental needs of the child and the cultural context. Z62.891 Sibling Relational Problem

This category may be used when the focus of clinical attention is a pattern of interaction among siblings that is associated with significant impairment in individual or family functioning or with development of symptoms in one or more of the siblings, or when a sibling relational problem is affecting the course, prognosis, or treatment of a sibling’s mental disorder or other medical condition. This category may be used for either children or adults if the focus is on the sibling relationship. Siblings in this context include full, half-, step-, foster, and adopted siblings. Z63.0 Relationship Distress With Spouse or Intimate Partner This category may be used when the major focus of the clinical contact is to address the quality of the intimate (spouse or partner) relationship or when the quality of that relationship is affecting the course, prognosis, or treatment of a mental disorder or other medical condition. Partners can be of the same or different genders. Typically, the relationship distress is associated with impaired functioning in behavioral, cognitive, or affective domains. Examples of behavioral problems include conflict resolution difficulty, withdrawal, and overinvolvement. Cognitive problems can manifest as chronic negative attributions of the other’s intentions or dismissals of the partner’s positive behaviors. Affective problems would include chronic sadness, apathy, and/or anger about the other partner. Problems Related to the Family Environment Z62.29 Upbringing Away From Parents This category may be used when the main focus of clinical attention pertains to issues regarding a child being raised away from the parents or when this separate upbringing affects the course, prognosis, or treatment of a mental disorder or other medical condition. The child could be one who is under state custody and placed in kin care or foster care. The child could also be one who is living in a nonparental relative’s home, or with friends, but whose out-of-home placement is not mandated or sanctioned by the courts. Problems related to a child living in a group home or orphanage are also included. This category excludes issues related to Z59.3 Problem Related to Living in a Residential Institution. Z62.898 Child Affected by Parental Relationship Distress This category may be used when the focus of clinical attention is the negative effects of parental relationship discord (e.g., high levels of conflict, distress, or disparagement) on a child in the family, including effects on the child’s mental disorder or other medical condition. Z63.5 Disruption of Family by Separation or Divorce This category may be used when partners in an intimate adult couple are living apart because of relationship problems or are in the process of divorce. Z63.8 High Expressed Emotion Level Within Family Expressed emotion is a construct used as a qualitative measure of the “amount” of emotion—in particular, hostility, emotional overinvolvement, and criticism directed toward a family member who is an identified patient—displayed in the family environment. This category may be used when a family’s high level of expressed emotion is the focus of clinical attention or is affecting the course, prognosis, or treatment of a family member’s mental disorder or other medical

condition. Educational Problems These categories may be used when an academic or educational problem is the focus of clinical attention or has an impact on the individual’s diagnosis, treatment, or prognosis. Problems to be considered include illiteracy or low-level literacy; lack of access to schooling owing to unavailability or unattainability; problems with academic performance (e.g., failing school examinations, receiving failing marks or grades) or underachievement (below what would be expected given the individual’s intellectual capacity); discord with teachers, school staff, or other students; problems related to inadequate teaching; and any other problems related to education and/or literacy. Z55.0 Illiteracy and Low-Level Literacy Z55.1 Schooling Unavailable and Unattainable Z55.2 Failed School Examinations Z55.3 Underachievement in School Z55.4 Educational Maladjustment and Discord With Teachers and Classmates Z55.8 Problems Related to Inadequate Teaching Z55.9 Other Problems Related to Education and Literacy Occupational Problems These categories may be used when an occupational problem is the focus of clinical attention or has an impact on the individual’s treatment or prognosis. Areas to be considered include problems with employment or in the work environment, including problems related to current military deployment status; unemployment; recent change of job; threat of job loss; stressful work schedule; uncertainty about career choices; sexual harassment on the job; other discord with boss, supervisor, co-workers, or others in the work environment; uncongenial or hostile work environments; other physical or mental strain related to work; sexual harassment on the job; and any other problems related to employment and/or occupation. Z56.82 Problem Related to Current Military Deployment Status This category may be used when an occupational problem directly related to an individual’s military deployment status is the focus of clinical attention or has an impact on the individual’s diagnosis, treatment, or prognosis. Psychological reactions to deployment are not included in this category; such reactions would be better captured as an adjustment disorder or another mental disorder. Z56.0 Unemployment Z56.1 Change of Job

Z56.2 Threat of Job Loss Z56.3 Stressful Work Schedule Z56.4 Discord With Boss and Workmates Z56.5 Uncongenial Work Environment Z56.6 Other Physical and Mental Strain Related to Work Z56.81 Sexual Harassment on the Job Z56.9 Other Problem Related to Employment Housing Problems Z59.01 Sheltered Homelessness This category may be used when sheltered homelessness has an impact on an individual’s treatment or prognosis. An individual is considered to be experiencing sheltered homelessness if the primary nighttime residence is a homeless shelter, a warming shelter, a domestic violence shelter, a motel, or in a temporary or transitional living situation. Z59.02 Unsheltered Homelessness This category may be used when unsheltered homelessness has an impact on an individual’s treatment or prognosis. An individual is considered to be experiencing unsheltered homelessness if residing in a place not meant for human habitation, such as a public space (e.g., tunnel, transportation station, mall), a building not intended for residential use (e.g., abandoned structure, unused factory), a car, a cave, a cardboard box, or some other ad hoc housing situation. Z59.1 Inadequate Housing This category may be used when lack of adequate housing has an impact on an individual’s treatment or prognosis. Examples of inadequate housing conditions include lack of heat (in cold temperatures) or electricity, infestation by insects or rodents, inadequate plumbing and toilet facilities, overcrowding, lack of adequate sleeping space, and excessive noise. It is important to consider cultural norms before assigning this category. Z59.2 Discord With Neighbor, Lodger, or Landlord This category may be used when discord with neighbors, lodgers, or a landlord is a focus of clinical attention or has an impact on the individual’s treatment or prognosis. Z59.3 Problem Related to Living in a Residential Institution This category may be used when a problem (or problems) related to living in a residential institution is a focus of clinical attention or has an impact on the individual’s treatment or prognosis. Psychological reactions to a change in living situation are not included in this category; such reactions would be better captured as an adjustment disorder. Z59.9 Other Housing Problem This category may be used when there is a problem related to housing circumstances other than as specified above.

Economic Problems These categories may be used when an economic problem is the focus of clinical attention or has an impact on the individual’s treatment or prognosis. Areas to be considered include lack of adequate food (food insecurity) or safe drinking water, extreme poverty, low income, insufficient social or health insurance or welfare support, or any other economic problems. Z59.41 Food Insecurity Z58.6 Lack of Safe Drinking Water Z59.5 Extreme Poverty Z59.6 Low Income Z59.7 Insufficient Social or Health Insurance or Welfare Support This category may be used for individuals who meet eligibility criteria for social or welfare support but are not receiving such support, who receive support that is insufficient to address their needs, or who otherwise lack access to needed insurance or support programs. Examples include inability to qualify for welfare support because of lack of proper documentation or evidence of address, inability to obtain adequate health insurance because of age or a preexisting condition, and denial of support owing to excessively stringent income or other requirements. Z59.9 Other Economic Problem This category may be used when there is a problem related to economic circumstances other than as specified above. Problems Related to the Social Environment Z60.2 Problem Related to Living Alone This category may be used when a problem associated with living alone is the focus of clinical attention or has an impact on the individual’s treatment or prognosis. Examples of such problems include chronic feelings of loneliness, isolation, and lack of structure in carrying out activities of daily living (e.g., irregular meal and sleep schedules, inconsistent performance of home maintenance chores). Z60.3 Acculturation Difficulty This category may be used when difficulty in adjusting to a new culture (e.g., following migration) is the focus of clinical attention or has an impact on the individual’s treatment or prognosis. Z60.4 Social Exclusion or Rejection This category may be used when there is an imbalance of social power such that there is recurrent social exclusion or rejection by others. Examples of social rejection include bullying, teasing, and intimidation by others; being targeted by others for verbal abuse and humiliation; and being purposefully excluded from the activities of peers, workmates, or others in one’s social environment.

Z60.5 Target of (Perceived) Adverse Discrimination or Persecution This category may be used when there is perceived or experienced discrimination against or persecution of the individual based on his or her membership (or perceived membership) in a specific category. Typically, such categories include gender or gender identity, race, ethnicity, religion, sexual orientation, country of origin, political beliefs, disability status, caste, social status, weight, and physical appearance. Z60.9 Other Problem Related to Social Environment This category may be used when there is a problem related to the individual’s social environment other than as specified above. Problems Related to Interaction With the Legal System These categories may be used when a problem related to interaction with the legal system is the focus of clinical attention or has an impact on the individual’s treatment or prognosis. Areas to be considered include conviction in criminal proceedings, imprisonment or other incarceration, problems related to release from prison, and problems related to other legal circumstances (e.g., civil litigation, child custody or support proceedings). Z65.0 Conviction in Criminal Proceedings Without Imprisonment Z65.1 Imprisonment or Other Incarceration Z65.2 Problems Related to Release From Prison Z65.3 Problems Related to Other Legal Circumstances (e.g., civil litigation, child custody or support proceedings) Problems Related to Other Psychosocial, Personal, and Environmental Circumstances Z72.9 Problem Related to Lifestyle This category may be used when a lifestyle problem is a specific focus of treatment or directly affects the course, prognosis, or treatment of a mental disorder or other medical condition. Examples of lifestyle problems include lack of physical exercise, inappropriate diet, high-risk sexual behavior, and poor sleep hygiene. A problem that is attributable to a symptom of a mental disorder should not be coded unless that problem is a specific focus of treatment or directly affects the course, prognosis, or treatment of the individual. In such cases, both the mental disorder and the lifestyle problem should be coded. Z64.0 Problems Related to Unwanted Pregnancy Z64.1 Problems Related to Multiparity Z64.4 Discord With Social Service Provider, Including Probation Officer, Case Manager, or Social Services Worker

Z65.4 Victim of Crime Z65.4 Victim of Terrorism or Torture Z65.5 Exposure to Disaster, War, or Other Hostilities Problems Related to Access to Medical and Other Health Care These categories may be used when a problem related to access to medical or other health care is the focus of clinical attention or has an impact on the individual’s treatment or prognosis. Z75.3 Unavailability or Inaccessibility of Health Care Facilities Z75.4 Unavailability or Inaccessibility of Other Helping Agencies Circumstances of Personal History Z91.49 Personal History of Psychological Trauma Z91.82 Personal History of Military Deployment Other Health Service Encounters for Counseling and Medical Advice Z31.5 Genetic Counseling This category may be used for individuals seeking genetic counseling to understand the risks of developing a mental disorder with a significant genetic component (e.g., bipolar disorder) for themselves and other family members, including their existing children, as well as the risks for their future children. Z70.9 Sex Counseling This category may be used when the individual seeks counseling related to sex education, sexual behavior, sexual orientation, sexual attitudes (embarrassment, timidity), others’ sexual behavior or orientation (e.g., spouse, partner, child), sexual enjoyment, or any other sex-related issue. Z71.3 Dietary Counseling This category may be used when the individual seeks counseling related to dietary issues like weight management. Z71.9 Other Counseling or Consultation This category may be used when counseling is provided or advice/consultation is sought for a problem that is not specified above or elsewhere in this chapter (e.g., counseling regarding drug abuse prevention in an adolescent). Additional Conditions or Problems That May Be a Focus of

Clinical Attention Z91.83 Wandering Associated With a Mental Disorder This category may be used for individuals with a mental disorder whose desire to walk about leads to significant clinical management or safety concerns. For example, individuals with major neurocognitive or neurodevelopmental disorders may experience a restless urge to wander that places them at risk for falls and causes them to leave supervised settings without needed accompaniment. This category excludes individuals whose intent is to escape an unwanted housing situation (e.g., children who are running away from home, individuals who no longer wish to remain in the hospital) or those who walk or pace as a result of medication-induced akathisia. Coding note: First code associated mental disorder (e.g., major neurocognitive disorder, autism spectrum disorder), then code Z91.83 wandering associated with [specific mental disorder]. Z63.4 Uncomplicated Bereavement This category may be used when the focus of clinical attention is a normal reaction to the death of a loved one. As part of their reaction to such a loss, some grieving individuals present with symptoms characteristic of a major depressive episode—for example, feelings of sadness and associated symptoms such as insomnia, poor appetite, and weight loss. The bereaved individual typically regards the depressed mood as “normal,” although the individual may seek professional help for relief of associated symptoms such as insomnia or anorexia. The duration and expression of “normal” bereavement vary considerably among different cultural groups. Further guidance in distinguishing grief from a major depressive episode and from prolonged grief disorder is provided in their respective texts. Z60.0 Phase of Life Problem This category may be used when a problem adjusting to a life-cycle transition (a particular developmental phase) is the focus of clinical attention or has an impact on the individual’s treatment or prognosis. Examples of such transitions include entering or completing school, leaving parental control, getting married, starting a new career, becoming a parent, adjusting to an “empty nest” after children leave home, and retiring. Z65.8 Religious or Spiritual Problem This category may be used when the focus of clinical attention is a religious or spiritual problem. Examples include distressing experiences that involve loss or questioning of faith, problems associated with conversion to a new faith, or questioning of spiritual values that may not necessarily be related to an organized church or religious institution. Z72.811 Adult Antisocial Behavior This category may be used when the focus of clinical attention is adult antisocial behavior that is not attributable to a mental disorder (e.g., conduct disorder, antisocial personality disorder). Examples include the behavior of some professional thieves, racketeers, or dealers in illegal substances.

Z72.810 Child or Adolescent Antisocial Behavior This category may be used when the focus of clinical attention is antisocial behavior in a child or adolescent that is not attributable to a mental disorder (e.g., intermittent explosive disorder, conduct disorder). Examples include isolated antisocial acts by children or adolescents (not a pattern of antisocial behavior). Z91.19 Nonadherence to Medical Treatment This category may be used when the focus of clinical attention is nonadherence to an important aspect of treatment for a mental disorder or another medical condition. Reasons for such nonadherence may include discomfort resulting from treatment (e.g., medication side effects), expense of treatment, personal value judgments or religious or cultural beliefs about the proposed treatment, age-related debility, and the presence of a mental disorder (e.g., schizophrenia, personality disorder). This category may be used only when the problem is sufficiently severe to warrant independent clinical attention and does not meet diagnostic criteria for psychological factors affecting other medical conditions. E66.9 Overweight or Obesity This category may be used when overweight or obesity is a focus of clinical attention. Z76.5 Malingering The essential feature of malingering is the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives such as avoiding military duty, avoiding work, obtaining financial compensation, evading criminal prosecution, or obtaining drugs. Under some circumstances, malingering may represent adaptive behavior—for example, feigning illness while a captive of the enemy during wartime. Malingering should be strongly considered if any combination of the following is noted: 1. Medicolegal context of presentation (e.g., the individual is referred by an attorney to the clinician for examination, or the individual self-refers while litigation or criminal charges are pending). 2. Marked discrepancy between the individual’s claimed stress or disability and the objective findings and observations. 3. Lack of cooperation during the diagnostic evaluation and in complying with the prescribed treatment regimen. 4. The presence of antisocial personality disorder. Malingering differs from factitious disorder in that the motivation for the symptom production in malingering is an external incentive, whereas in factitious disorder external incentives are absent. Malingering is differentiated from functional neurological symptom disorder (conversion disorder) and other somatic symptom–related mental disorders by the intentional production of symptoms and by the obvious external incentives associated with it. Definite evidence of feigning (such as clear evidence that loss of function is present during the examination but not at home) would suggest a diagnosis of factitious disorder if the individual’s apparent aim is to assume the sick role, or malingering if it is to obtain an incentive, such as money. R41.81 Age-Related Cognitive Decline This category may be used when the focus of clinical attention is an objectively identified

decline in cognitive functioning consequent to the aging process that is within normal limits given the individual’s age. Individuals with this condition may report problems remembering names or appointments or may experience difficulty in solving complex problems. This category should be considered only after it has been determined that the cognitive impairment is not better explained by a specific mental disorder or attributable to a neurological condition. R41.83 Borderline Intellectual Functioning This category may be used when an individual’s borderline intellectual functioning is the focus of clinical attention or has an impact on the individual’s treatment or prognosis. Differentiating borderline intellectual functioning and mild intellectual developmental disorder (intellectual disability) requires careful assessment of intellectual and adaptive functions and their discrepancies, particularly in the presence of co-occurring mental disorders that may affect patient compliance with standardized testing procedures (e.g., schizophrenia or attentiondeficit/hyperactivity disorder, with severe impulsivity).