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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