Overview of diagnosis coding for behavioral health services

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

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