2025 ICD-10-CM code R45.88
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Symptoms, signs and abnormal clinical and laboratory findings - Symptoms and signs involving emotional state Chapter 18: Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99) Feed
Nonsuicidal self-harm, encompassing self-injury without suicidal intent.
Modifiers may be applicable depending on the circumstances of the encounter and the services rendered. Consult the appropriate modifier guidelines for more information.
The medical necessity for coding R45.88 is established when the patient presents with self-inflicted injuries and the physician determines that the self-harm was intentional but without suicidal intent.The presence of underlying mental health conditions that contribute to the self-harm behavior would also support medical necessity.Documentation should clearly link the self-harm to a specific need for medical care, such as treatment of the injuries or mental health intervention.
The clinical responsibility for coding R45.88 rests with the physician or qualified healthcare professional who assesses and diagnoses the patient. They must determine if the self-harm was intentional and whether it was associated with suicidal ideation.Accurate documentation is crucial for proper coding and reimbursement.
- Chapter 18: Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)
- R45.88 falls under the broader category of symptoms and signs involving emotional state (R45.8).
In simple words: This code describes when someone hurts themselves on purpose, but they don't want to die.It might be because they're coping with difficult feelings or for other reasons, not to kill themselves. The doctor will use this code along with other codes that might describe the injuries or the reason for the self-harm.
This code, R45.88, is used to classify instances of self-harm where there is no evidence of suicidal intent.It encompasses a range of behaviors, such as cutting, burning, or other forms of self-inflicted injury, performed as a coping mechanism or for reasons other than ending one's life.The diagnosis should be supported by clinical documentation that clearly distinguishes the self-harm from a suicide attempt.This code is used in addition to any codes for injuries sustained during the self-harm episode or for any underlying mental health conditions.
Example 1: A 15-year-old patient presents to their physician with multiple self-inflicted superficial cuts on their arms. They report engaging in self-cutting as a way to cope with intense emotional distress, but deny any suicidal thoughts or plans.R45.88 is used to code the non-suicidal self-harm in addition to any other codes that capture the patient's mental health status., A 22-year-old adult patient is admitted to the hospital after self-inflicting burns on their legs.The patient reports feeling overwhelmed by stress and anxiety, and uses the self-harm as a maladaptive coping mechanism.The absence of suicidal ideation supports the use of R45.88, in addition to any codes related to their injuries and mental health diagnoses., A 30-year-old patient is seen in a therapist's office for self-harm behaviors.During the session, the patient explains that they self-harm to release pent-up emotions, and the therapist notes the absence of suicidal intent in the patient's statements and behavior.The therapist documents the appropriate ICD-10 code (R45.88) along with any relevant diagnoses and treatment plans.
Detailed clinical documentation is crucial for accurate coding of R45.88.This should include:* A clear statement indicating that the self-harm was intentional.* A comprehensive assessment of suicidal ideation, including thoughts, plans, and intent.* A description of the method and extent of the self-harm.* Documentation of any injuries sustained.* Detailed information on the patient's mental health status and any co-morbidities.* A thorough explanation of the reasons behind the self-harm behavior, ideally obtained from the patient's perspective.
** Accurate coding of R45.88 relies heavily on comprehensive and clear documentation.Any inconsistencies or lack of clarity in the medical record may lead to coding errors and potential reimbursement issues.Always cross-reference with the official ICD-10-CM guidelines to ensure accurate coding practices.
- Payment Status: Active
- Modifier TC rule: Not applicable.
- Specialties:Psychiatry, Psychology, Emergency Medicine, General Practice
- Place of Service:Office, Hospital (Inpatient or Outpatient), Emergency Room, Mental Health Facility