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How to Write a Diagnosis According to DSM-5 and ICD-10-CM
An Aid for MSW Students The DSM-5 manual has very little in it that directly explains how to code a full diagnosis. It assumes considerable outside knowledge because it was designed for working providers. Pages 21 to 23 in the DSM-5 manual describe general changes in the elements of coding a diagnosis. This article is a relevant summary of mental health coding directions for social work students new to the process. While all social workers need to know how to read and interpret diagnosis, state laws determine if you can provide a direct diagnosis yourself. In most states, Licensed Clinical Social Workers do assess and diagnose. Please look up your own state laws.
“There are specific recording protocols for these diagnostic codes that were established by WHO (the World Health Organization), the U.S. Centers for Medicare and Medicaid Services (CMS) and the Centers for Disease Control and Prevention’s National Center for Health Statistics to insure consistent, international recording.” (2013, American Psychiatric Association, DSM-5, p. 23).
Directions for diagnostic coding are updated regularly so professionals should always check the following resources:
a. CMS: Center for Medicare and Medicaid
Serviceshttp://www.roadto10.org/icd-10-basics/ or https://www.cms.gov/Medicare/Coding/ICD10/index.html
b. The Centers for Disease Control and Prevention: www.cdc.gov/nchs/icd/icd10cm/htm
c. The National Center for Health Statistics:
Several associations also provide directions to health care providers in published materials (APA, 2014). Among those are the American Medical Association and the American Psychiatric Associations. CHANGES IN DSM-5 First of all, the Axis system of coding that was part of DSM-IV-TR has been discontinued completely. It has been replaced by a simple “list” in a particular order of priority to the current treatment needs. “Prof Script” SOCW Homework/Due 12 Sep @ 1600
Because of the need to give providers in the country time to adjust to ICD-10, the DSM- 5 shows the “old” code and the current code. As of October 1, 2015, the United States officially stopped using ICD-9-CM coding completely (the old code). Today, the United States is only using ICD-10-CM. For those who don’t recognize that abbreviation, ICD is simply the abbreviation for the International Classification of Diseases, and the 9 or 10 simply represents the edition. Both ICD-9 and ICD-10 were included in the DSM-5 to help smooth the transition. You will see below both sets of codes. ALWAYS ignore the ICD-9 codes and use only the ICD-10-CM code in diagnosis. HOW TO CODE. “Prof Script” SOCW Homework/Due 12 Sep @ 1600
The ICD-10-CM codes are listed INSIDE the parentheses in the screen shot below. They are in a lighter, grey print. Use only that code. For mental health conditions they always state with an alphabet letter (usually F) followed by 3–7 numbers. Each diagnosis will need a code that is written BEFORE the words. As seen below, for Schizophrenia, the correct code to use is F20.9. The heading of any illness will always have at least the first three characters of the code right in the heading of the diagnostic criteria box.
The older (DSM-IV-TR) names of some disorders can sometimes be found after the current name. Only use the current “name” for the illness in a diagnosis. For Schizophrenia the diagnosis would look like this:
F20.9 Schizophrenia. For Schizophrenia, there are no “additional” characters in spaces 5, 6, and 7. For some illnesses, code numbers must be added in the 4th, 5th, or 6th spaces to individualize a condition. Spaces 4–6 provide greater detail of causes, location details, and severity. For example, here are two codes for Mania:
F30.10 Manic episode without psychotic symptoms, unspecified
F30.11 Manic episode without psychotic symptoms, mild
A code is invalid if it has not been coded to the full number of characters required. A code using only the first three digits is to be used only if it is not further subdivided. The diagnostic criteria box will always tell you if a code must be sub- divided. Many disorders have more than one ICD code offered for the first three digits. This happens only when there are common, clearly identified SUBTYPES to the illness. Disorders with subtypes won’t have ICD codes at the top of the diagnostic criteria box (where the disorder name is). If you do not see a code at the top of the Diagnostic Criteria box, look for the correct codes at the bottom of the diagnostic criteria box. Often the box will use words to identify the need to further individualize by saying: “Specify if” or “Specify whether.” You may also be asked to set a “severity level.”
For example, here are two subtypes for Schizoaffective Disorder: F25.0 Schizoaffective disorder, bipolar type F25.1 Schizoaffective disorder, depressive type Here are the subtypes for Agoraphobia:
F40.00 Agoraphobia, unspecified F40.01 Agoraphobia with panic disorder F40.02 Agoraphobia without panic disorder
The wording “specify whether” tells you that the subtypes that follow are mutually exclusive.
On page 106, after the subtype for Schizoaffective Disorder is identified, even more individualization is called for in that diagnostic box: “Specify if” is followed by “Specify current severity.” Both details are required. These terms prompt the clinician to further detail the course of the illness and the way to measure the severity of a presentation. ALWAYS check for coding notes which will also give you directions. For example, in addition to our subtypes for Schizoaffective Disorder, if Catatonia is present an additional code will be found in the coding note.
Now our diagnosis looks like this:
• F25.0 Schizoaffective Disorder, Bipolar Type. • F06.1 Catatonia (associated with another mental disorder)
Some disorders such as the substance/medication-induced disorders (which use individual substance titles) have more complex codes for their subtypes. When this happens there is always a table and a coding note found at the bottom of the diagnostic criteria box. The DSM-5 also has online assessment measures to help in diagnosis. These are available at:
https://www.psychiatry.org/psychiatrists/practice/dsm/dsm-5/online-assessment- measures Be aware that some diagnoses use the same code because the ICD has limitations that are already being updated to ICD-11. Hoarding disorder and obsessive-compulsive disorder share the same code in ICD-10-CM up until October of 2016. This will be updated by the Centers for Medicare and Medicaid Services so always check there and at the National Center for Health Statistics for updated coding on those disorders that
“share” a code. As of October 2016 the CMS has alerted providers to use: F42.2 for OCD and to use F42.3 for Hoarding Disorder.
HOW TO LIST MULTIPLE CODES Agencies and Insurance Carriers are allowed to use their own forms (within limits) for billing. Formal diagnosis in DSM-5 combines Axes I, II, and III into one list that contains all relevant mental disorders, including personality disorders, disabilities, as well as other relevant medical diagnoses. DSM-5 also expands the psychosocial stressors that a patient might be experiencing. These are now called “Other conditions that are a focus of treatment” and most of them begin with the letter “Z.” These conditions which are critical to psycho-social treatment (formerly known as the “V-codes” are found on page 715 in the manual. In a diagnostic list, always List the Principal diagnosis first (the reason for the visit if in an outpatient setting). Other mental health co-morbid diagnoses will follow in order of priority to the treatment or focus of attention.
1. RULE A: Here is a diagnosis list where our client has a mental disorder as the reason for the visit, with an additional medical condition unrelated to the mental disorder diagnosis. OTHER psychosocial factors relevant to the service are listed after mental health conditions and physical conditions:
• F40.00 Agoraphobia • K7030 Alcoholic cirrhosis of liver without ascites (by patient report) • Z60.3 Acculturation difficulty • Z72.0 Tobacco use disorder, mild (nicotine use)
So the order of priority above is: 1. principal mental health diagnosis/s, 2. medical factors, and 3. psychosocial needs.
2. RULE B: If our client has a clinical diagnosis of a mental health problem as the principal diagnosis (all F. codes), with the presence of a second, additional mental disorder but without the medical problem of Cirrhosis, the diagnosis looks like this:
• F40.00 Agoraphobia • F50.01 Anorexia nervosa, restricting subtype • Z60.3 Acculturation difficulty. • Z72.0 Tobacco use disorder, mild (nicotine use)
Notice that other (psychosocial) conditions receiving interventions are still listed as Z codes.
3. RULE C: An exception to rules (a) and (b) occurs only when the “other medical
condition” is thought to be causing the mental disorder. In such cases the
medical condition should be listed first. Here damage from the liver is also causing a Neurocognitive disorder.
• K7030 Alcoholic cirrhosis of liver without ascites • F10.988 Mild Neurocognitive disorder, without Alcohol use. • Z60.3 Acculturation difficulty • Z72.0 Tobacco use disorder, mild (nicotine use)
In diagnosis one has to first rule out if the condition is being caused by a physical illness, then if it is caused by a substance use problem, and only then are mental disorders investigated.
OTHER CONVENTIONS In older diagnostics, clinicians often used “diagnosis deferred” (799.9 in ICD-9) when they were not ready to assign a diagnosis. This was used mostly on Axis 11 when personality disorders were being considered. This was charted as “ruling out” possibilities.
In DSM-5 the closest option to this in ICD-10 is R69.0 which is Illness, unspecified which is used for physical conditions. If the reasons for delaying diagnosis is that a full presentation is not documentable because of limited assessment, then the “Provisional” diagnosis is preferred for mental health conditions.
The APA tells us to use provisional “when you have a strong ‘presumption’ that the full criteria will ultimately be met for a disorder but not enough information is available to make a firm diagnosis.” (2013, APA. p.23). The word “provisional” simply follows the full diagnosis label:
• F40.00 Agoraphobia, provisional When syndromes are present but they do not rise to the level of meeting all the criteria needed for full presentation, are mixed or below the level that they are causing significant distress, most chapters will have an “Other Specified Disorder” category which should be used. If used, the provider then “specifies” the disorder that the “other specified condition comes “close to.” There are detailed options in many of these categories. For example, there are several options for F28 Other Specified Schizophrenia Spectrum and Psychotic Disorder (see p. 122). While each section in DSM-5 has an “UNSPECIFIED” code, we are asked not to use this in routine treatment situations. Insurance carriers have variable rules about this label. The CMS actually designed the term for situations in which there is insufficient information to make a diagnosis – for example in settings like Emergency Rooms. If you are using “UNSPECIFIED” be prepared that many insurance carriers will deny services and payments on the basis that there is no “medical necessity” present.
References American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental
Disorders (5th ed.). Arlington, VA: American Psychiatric Association. American Psychiatric Association. (2014). Frequently asked questions about DSM-5
implementation—for clinicians updated 10/7/14. Retrieved from: http://www.dsm5.org/Documents/FINAL%20FAQ%20for%20Clinicians%20PDF% 2010-7-14.pdf
Center for Medicare and Medicaid Services. (2015). ICD-10 basics. Retrieved Jan, 6,
2016 from: http://www.roadto10.org/icd-10-basics/ Center for Disease Control. (2017). ICD-10-CM official guidelines for coding and
reporting: FY 2017 (October 1, 2016–September 30, 2017). Retrieved March 29, 2017 from: http://www.cdc.gov/nchs/data/icd/10cmguidelines_2017_final.pdf
Adapted from the above materials by Dr. Diane H. Ranes, PhD. LCSW. 10.14.2016