Written by: Compliance blogger
Originally Posted 3/21/2019
Reposted October 2020
What do you do when you suspect that one of your patients is faking their medical symptoms?
In some cases, you may find yourself looking for signs of a rare disorder connected with this type of behavior called Munchausen Syndrome. However, this condition must be confirmed before it is coded in the medical record. In this article, we discuss not only some common warning signs of this condition that you might encounter but also how to code it accurately once it is verified.
What Is Munchausen Syndrome?
Factitious Disorder Imposed on Self (a.k.a. Munchausen Syndrome)
The Mayo Clinic states when someone has factitious disorder imposed on self, commonly referred to as Munchausen Syndrome, they pretend to have an illness by either causing themselves to exhibit medical symptoms or falsely reporting symptoms. For example, they might fabricate their medical history, exaggerate symptoms they already have, injure themselves, inject themselves with unsafe substances or medications, or tamper with laboratory tests.
The Cleveland Clinic indicates because of behaviors they may undertake to be seen as sick, people with factitious disorder are often at risk for complications related to unnecessary surgeries, injuries from self-inflicted medical conditions, substance abuse, and other issues. The Cleveland Clinic estimates that as few as 1% of hospital patients meet the criteria for this condition. However, it can be difficult to count the number of people with Munchausen Syndrome accurately, as they often seek treatment at multiple facilities.
While the ultimate causes of factitious disorder are unknown, some risk factors may increase the probability of an individual developing this disorder, such as childhood trauma or abuse, a serious illness during childhood, or personality disorders.
One important distinction that must be made regarding this behavior is that if it is inflicted on another person, it is a serious form of abuse.
Medical child abuse (MCA), formerly Munchausen syndrome by proxy (MSBP), is a serious and potentially fatal form of child abuse
Factitious disorder by proxy, also known as Munchausen Syndrome by Proxy, is when a caregiver either falsely reports or causes an illness or injury in a person under their care. Potential victims of factitious disorder by proxy can include children, elderly adults, or individuals with disabilities. The perpetrator's goal for the behavior is to meet personal emotional needs by forcing unnecessary or misguided medical or psychological treatment. Generally, a mother is the perpetrator and her child is the victim.
For example, an abusive caretaker might perpetrate this abuse on a child by:
- Withholding food to make it appear that the child cannot gain weight
- Making up lab results
- Adding blood to the child’s urine samples
- Giving the child drugs to make them vomit or have diarrhea
The Federal Bureau of Investigation (FBI) Training Division has published a Law Enforcement Bulletin discussing Munchausen Syndrome by Proxy. In this bulletin, they make it very clear that people who commit this type of abuse are doing so intentionally. In fact, they note that even the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) refers to people who practice the type of deception seen in factitious disorder by proxy as perpetrators.
Whether imposed on self or others, there are some warning signs that healthcare providers can look for to determine if a patient’s symptoms or suspected illness may be related to Munchausen Syndrome.
What are Some Warning Signs?
There are many different points at which a healthcare professional might begin to suspect that a patient claiming to be ill is actually experiencing Munchausen Syndrome. Some red flags in patient behavior that might indicate factitious disorder imposed on self include:
- Inconsistent medical history
- The addition of new symptoms following any negative test results
- Symptoms that are not actually observed by clinicians, and occur when the patient is alone
- An unusually detailed knowledge of hospitals, medical terminology, and illness definitions
- Avoidance of additional information sources, such as their previous medical records, other doctors, or family members
- An unusual eagerness to undergo medical tests and procedures
Providers may also use the criteria for factitious disorder provided in the DSM-5 as guidance when determining if a patient falls into this category.
Munchausen Child Abuse (Munchausen Syndrome by Proxy)
With MCA or factitious disorder by proxy (MSBP), doctors might notice warning signs in both the perpetrators and the victims. For example, caretakers committing Munchausen Syndrome by Proxy have often worked in the healthcare field and thus have extensive knowledge about medical care, enabling them to describe symptoms in detail. Parents committing factitious disorder by proxy also tend to be very involved with their children, and seem very dedicated to their care. This devotion can sometimes make it difficult for healthcare professionals to identify an instance of factitious disorder by proxy.
Other signs are observed in the victim (or victims). For example, if a child has unusual symptoms that match neither their test results nor any particular illness, that could be an indication of MCA. It is also suspicious when a child's symptoms are reported by their caretaker but not witnessed by healthcare professionals, such as symptoms that disappear when the child is hospitalized, but reemerge as soon as they return home. Drugs or chemicals found in urine, stool, or blood samples from the child can also increase a doctor’s suspicion of MCA.
It is NOT isolated to children
These warning signs could also apply to other potential victims of factitious disorder by proxy, such as elderly parents. Remember, as factitious disorder by proxy is a serious form of abuse, confirmed instances of it should be reported to the appropriate authorities.
How Would I Code Munchausen Syndrome?
ICD-10-CM Guidelines uses Munchausen's Syndrome by Proxy or MSBP. According to the Offical Coding Guidelines new in 2019 and carried forward to 2020 and 2021, when coding factitious disorder imposed on self, you should use the appropriate code from subcategory F68.1-
Factitious disorder imposed on self, unspecified
Factitious disorder imposed on self, with predominately psychological signs and symptoms
Factitious disorder imposed on self, with predominately physical signs and symptoms
Factitious disorder imposed on self, with combined psychological and physical signs and symptoms
MSBP or when this behavior is inflicted on a child or other dependent individual, it is the perpetrator, not the victim, who receives the diagnosis of factitious disorder by proxy. The code for this diagnosis is F68.A
Factitious disorder imposed on another
Factitious disorder by proxy
Munchausen's by proxy
Assign T74 or T76 to the victim of a person/patient diagnosed with factitious disorder by proxy or for MSBP:
Description of Confirmed Cases
T74.01XA - T74.02XS
T74.0 Neglect or abandonment, confirmed
T74.11XA - T74.12XS
T74.1 Physical abuse, confirmed
T74.21XA - T74.22XS
T74.2 Sexual abuse, confirmed
T74.31XA - T74.32XS
T74.3 Psychological abuse, confirmed
T74.4XXA - T74.4XXS
T74.4 Shaken infant syndrome
T74.51XA - T74.52XS
T74.5 Forced sexual exploitation, confirmed
T74.61XA - T74.62XS
T74.6 Forced labor exploitation, confirmed
T74.91XA - T74.92XS
T74.9 Unspecified maltreatment, confirmed
Description of Suspected Cases
T76.01XA - T76.02XS
T76.0 Neglect or abandonment, confirmed
T76.11XA - T76.12XS
T76.1 Physical abuse, confirmed
T76.21XA - T76.22XS
T76.2 Sexual abuse, confirmed
T76.31XA - T76.32XS
T76.3 Psychological abuse, confirmed
T76.4XXA - T76.4XXS
T76.4 Shaken infant syndrome
T76.51XA - T76.52XS
T76.5 Forced sexual exploitation, confirmed
T76.61XA - T76.62XS
T76.6 Forced labor exploitation, confirmed
T76.91XA - T76.92XS
T76.9 Unspecified maltreatment, confirmed
The Official Guidelines also recommend that coders look at Section I.C.19.f., Adult and child abuse, neglect and other maltreatment.
If you notice a patient at your healthcare organization whose symptoms appear to indicate that they may fall under one of these coding categories, you should discuss it with the doctor who would then make the final diagnosis.