Match diagnoses on the claim form to those listed in assessment

The diagnosis codes on the claim form should match those in the note.

• If the assessment says “stable on medications” or “doing well,” it isn’t clear how many conditions were managed and treated
• List conditions managed and treated in assessment
• Note their status
• Select a specific diagnosis code, when possible

Diagnosis coding issues for behavioral health services

• Avoid continuing to use diagnosis codes “with psychosis” “current episode manic” when they no longer describe the condition
• If a substance abuse disorder is in remission, select that code rather than “uncomplicated”
• If the patient meets the criteria for major depressive disorder or anxiety disorder, use those codes rather than adjustment disorder with depression/anxiety
• Avoid code F32.9, major depressive disorder, single episode, unspecified. This code does not have a risk adjustment factor. Use any other code from F32 major depressive disorder single episode, or F33, major depressive disorder, recurrent