Post-Traumatic Stress Disorder (PTSD) Documentation Guide
Trauma-related disorder characterized by intrusive memories, avoidance, negative cognitions, and hyperarousal following exposure to a traumatic event.
ICD-10 Codes: F43.10, F43.11, F43.12
Common Symptoms
- Intrusive memories or flashbacks
- Avoidance behaviors
- Hypervigilance
- Sleep disturbances
- Emotional numbing
Key Documentation Elements
- Trauma type and exposure history
- DSM-5 cluster symptoms (intrusion, avoidance, cognition/mood, arousal)
- PCL-5 or CAPS-5 score if administered
- Current psychotherapy type and frequency
- Pharmacotherapy regimen and response
Documentation Challenges
- Documenting trauma exposure sensitively and accurately
- Capturing all four DSM-5 symptom clusters
- Recording PCL-5 or other validated screening scores
- Tracking treatment response for therapy and pharmacotherapy
Billing Considerations
- Unspecified (F43.10) vs acute (F43.11) vs chronic (F43.12) distinction
- Psychotherapy documentation and time-based billing
- Comorbid condition co-coding (depression, substance use)
Frequently Asked Questions
How is PTSD coded in ICD-10?
PTSD uses F43.10 (unspecified), F43.11 (acute, symptoms <3 months), and F43.12 (chronic, symptoms >3 months). Scribeable determines chronicity from your documented symptom duration and onset.
How does Scribeable help with PTSD documentation?
Scribeable captures all four DSM-5 symptom clusters, screening scores, therapy progress, and medication management from your encounter while maintaining sensitivity, ensuring complete documentation for ongoing trauma-focused care.