How to Write a Diagnosis According to the DSM-5
An Aid for MSW Students As you write a diagnosis, keep in mind that “[there] are specific recording protocols for these diagnostic codes…to insure consistent, international recording” (American Psychiatric Association, 2013, p. 23).
Writing a Diagnosis A diagnosis is written as a simple list in order of priority to the current treatment needs.
F33.1 Major depressive disorder, moderate, recurrent, with seasonal pattern F41.1 Generalized anxiety disorder Z60.3 Acculturation difficulty
Each diagnosis needs an ICD code that is written before the name of the diagnosis. The older (DSM-IV-TR) names of some disorders can sometimes be found after the current name. However, to avoid confusion, only use the current name for the illness in a diagnosis. ICD Codes The DSM-5 includes codes for the International Classification of Diseases. Both ICD-9 and ICD-10 are included in the DSM-5. Always ignore the ICD-9 codes and use only the ICD-10-CM codes in diagnosis. The ICD-10-CM codes are listed inside the parentheses in the screen shot below.
HOW TO CODE
For mental health conditions, codes always start with a letter (usually F), followed by 2– 6 digits. A code is not valid unless it has been coded to the full number of digits required. A code with only the first three digits is used only if that condition is not further subdivided within the DSM-5. For example, for schizophrenia, there are no additional characters in spaces 4, 5, 6, and 7.
F20.9 Schizophrenia In other cases, 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
Many disorders have more than one ICD code when there are common, clearly identified subtypes to the illness. The diagnostic criteria box always tells you if a code must be subdivided. 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 box. Often the box prompts for further individualization by saying “Specify if” or “Specify whether.” You may also be asked to set a severity level. The wording “specify whether” tells you that the subtypes that follow are mutually exclusive. For example, here are two subtypes for schizoaffective disorder: F25.0 Schizoaffective disorder, bipolar type F25.1 Schizoaffective disorder, depressive type
Always check for coding notes for further directions. For example, in addition to our subtypes for schizoaffective disorder, if catatonia is present, an additional code is 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) After the subtype for schizoaffective disorder is identified, the diagnostic box requires even more individualization: “Specify if” is followed by “Specify current severity.” These terms prompt the clinician to further detail the course of the illness and the way to measure the severity of a presentation. F25.0 Schizoaffective disorder, bipolar type, multiple episodes, currently in acute episode, symptom severity F06.1 Catatonia (associated with another mental disorder) Some disorders such as the substance/medication-induced disorders 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. Be aware that some diagnoses use the same code because the ICD has limitations that are already being updated for ICD-11. Always check the Centers for Medicare and
Medicaid Services (CMS) and the National Center for Health Statistics for updated coding on those disorders that share a code. HOW TO LIST MULTIPLE CODES Formal DSM-5 diagnosis combines into one list all relevant mental disorders, including personality disorders, disabilities, and other relevant medical diagnoses. The 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 psychosocial treatment (formerly known as the V codes), are found on p. 715 in the manual. In a diagnostic list, always place the principal diagnosis first (the reason for the visit, if in an outpatient setting). Other mental health co-morbid diagnoses follow in order of priority to the treatment or focus of attention.
1. RULE A: In this diagnostic list, a mental disorder was the reason for the visit, with the client experiencing 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)
The order of priority above is (a) principal mental health diagnosis, (b) medical factors, and (c) psychosocial needs.
2. RULE B: If the client above 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)
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 to 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)
OTHER CONVENTIONS In diagnosis, a clinician must 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. A diagnosis should only be provided once a comprehensive assessment has been completed. The DSM-5 has online assessment measures to help in diagnosis. In older diagnostics, clinicians used “diagnosis deferred” (799.9 in ICD-9) when they were not ready to assign a diagnosis. There is no analogous code in the ICD-10; instead, a clinician should use “provisional” or “other specified disorder,” when appropriate. A provisional diagnosis is preferred for mental health conditions, if the reason for delaying diagnosis is that sufficient criteria to meet diagnostic category is not documentable because of limited assessment. The APA (2013) tells clinicians to use a provisional diagnosis “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” (p. 23). The word provisional simply follows the full diagnostic label:
F40.00 Agoraphobia, provisional When symptoms are present but do not meet all the criteria needed for a diagnosis, such as when symptoms are mixed or below the diagnostic threshold but are causing significant distress, most chapters in the DSM-5 have an “Other Specified Disorder” category. If used, the clinician then specifies the presentation according to specifiers provided in the diagnostic box. For example, there are several options for F28 Other Specified Schizophrenia Spectrum and Other Psychotic Disorder, one of example of which is shown below:
F28 Other specified schizophrenia spectrum disorder, persistent auditory hallucinations
While each chapter in the DSM-5 has an “UNSPECIFIED” code, clinicians 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 for many insurance carriers to deny services and payments on the basis that there is no “medical necessity” present.
While all social workers need to know how to read and interpret diagnoses, 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 state laws. References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental
disorders (5th ed.). Arlington, VA: Author. American Psychiatric Association. (2018). DSM–5 frequently asked questions.
Retrieved from https://www.psychiatry.org/psychiatrists/practice/dsm/feedback- and-questions/frequently-asked-questions
Centers for Disease Control and Prevention. (2017a). ICD-10-CM official guidelines for
coding and reporting: FY 2017 (October 1, 2016–September 30, 2017). Retrieved from http://www.cdc.gov/nchs/data/icd/10cmguidelines_2017_final.pdf
Centers for Disease Control and Prevention. (2017b). International classification of
diseases, tenth revision, clinical modification (ICD-10-CM). Retrieved from https://www.cdc.gov/nchs/icd/icd10cm.htm
Centers for Medicare and Medicaid Services. (2017). Provider resources. Retrieved
from https://www.cms.gov/Medicare/Coding/ICD10/ProviderResources.html Material in this guide has been adapted from the referenced materials by Dr. Diane H. Ranes, PhD, LCSW.