F43.10 — Post-Traumatic Stress Disorder

Clinical Description

F43.10 identifies post-traumatic stress disorder (PTSD) without specification of acute or chronic duration. PTSD requires exposure to a traumatic event and symptoms across four clusters: intrusion, avoidance, negative cognitions/mood, and hyperarousal persisting for more than one month.

Key Symptoms to Document

When using F43.10, your documentation should reference these symptoms:

• Intrusive memories, flashbacks, or nightmares related to the trauma
• Avoidance of trauma-related stimuli (places, people, conversations)
• Negative alterations in cognition and mood (e.g., persistent blame, emotional numbing)
• Hyperarousal symptoms including hypervigilance and exaggerated startle response
• Sleep disturbance and irritability
• Difficulty concentrating

Common Interventions to Document

Evidence-based interventions typically documented with this diagnosis:

• Cognitive Processing Therapy (CPT)
• Prolonged Exposure Therapy (PE)
• Eye Movement Desensitization and Reprocessing (EMDR)
• SSRI pharmacotherapy (sertraline, paroxetine — FDA-approved for PTSD)
• Trauma-focused CBT

CPT Code Pairings

Common CPT codes used when billing with F43.10:

• 90791 — Psychiatric diagnostic evaluation
• 90837 — Individual psychotherapy, 60 minutes
• 90834 — Individual psychotherapy, 45 minutes
• 96127 — Brief emotional/behavioral assessment (e.g., PCL-5)
• 90853 — Group psychotherapy

Documentation Tips

• Document the index trauma meeting DSM-5 Criterion A (direct exposure, witnessing, learning about, or repeated exposure to aversive details).
• Record symptoms from all four PTSD clusters: intrusion, avoidance, negative cognitions/mood, and arousal/reactivity.
• Note symptom duration (must exceed 1 month) and distinguish from Acute Stress Disorder if under 1 month.
• Include PCL-5 score to quantify severity and track treatment response.
• Document safety assessment including suicidal ideation, self-harm, and substance use.

Differential Diagnosis Considerations

When documenting F43.10, consider and rule out:

• Acute stress disorder (F43.0)
• Adjustment disorder (F43.2x)
• Major depressive disorder (F32.x / F33.x)
• Generalized anxiety disorder (F41.1)
• Borderline personality disorder (F60.3)
• Traumatic brain injury sequelae

Screening Tools

Standardized measures commonly used with this diagnosis:

• PCL-5 (PTSD Checklist for DSM-5)
• PC-PTSD-5 (Primary Care PTSD Screen)
• CAPS-5 (Clinician-Administered PTSD Scale)
• IES-R (Impact of Event Scale — Revised)
• Life Events Checklist (LEC-5)