Diagnosis

A covered DSM-5-TR diagnosis is required for all clients in order to bill commercial insurance for a service.  Additionally, progress notes cannot be signed unless a diagnosis is entered in the designated required field of the note. To see how to enter a diagnosis in AdvancedMD, please reference this quick video

Diagnosis Requirements

In addition to including the primary diagnosis (secondary and tertiary as well, if applicable) in every progress note, you must also clearly identify the associated symptoms and functional impairments the client experiences in their life related to the diagnosis. Examples of areas of functional impairments include challenges in social/interpersonal, occupational/educational, health/medical compliance, and/or ability to maintain safety for either self or others. This clinical information is required and is an essential step in demonstrating medical necessity for the service being provided. 

Selection of therapeutic approaches and clinical interventions being used in session should also reflect best practices for treatment of the presenting problem and diagnosis(es), and clearly illustrate how they are targeting the clients treatment needs.

 

Diagnosis FAQ

What is meant by “covered” diagnosis? 

  • When entering a diagnosis, only F codes are to be used.  Z codes and R codes are not reimbursed by commercial insurance as a primary diagnosis. You can add Z and R code diagnoses after the primary F code diagnosis, if relevant for your client. If for any reason the diagnosis code you have entered is not covered, you will be contacted by billing. 

What if I am not able to determine an official diagnosis during the Initial Assessment, but I do think the client needs treatment?

  • It’s not uncommon to need some additional time to further evaluate a client's symptoms and engage in a differential diagnosis process, however you cannot sign the note (nor bill for the service) if you don't list a billable diagnosis. In these cases, it is advisable to consider if use of an interim “unspecified” diagnosis may be clinically indicated until you can confirm something more precise. You also may use “F99 - Mental disorder, not otherwise specified” for 1-2 sessions while you further confirm the diagnosis. 

 

What if my client doesn’t meet criteria for a DSM diagnosis, but still wants therapy?

  • If a client does not meet criteria for a covered DSM Diagnosis (F Code), commercial payers will not reimburse for the service.  Clients who would like to engage in therapy services but do not meet criteria for a covered diagnosis have the option to still engage in care, but must be self pay. You are welcome to still use our EHR and billing services for private pay clients. Our private pay rate for clients is $150 for individual sessions and $165 for family/couples sessions. You will be compensated for these visits at your contracted hourly rate.

 

When should I update or change a diagnosis?

  • Diagnoses are expected to reflect your best understanding at the time you assign them.  As more information is gathered, it is acceptable that your diagnosis might change. Any time your clinical assessment of a client's diagnosis changes - possibly sparked by a presentation of new or changing symptoms, new information being disclosed, or clinical progress made, you must update the diagnosis. An industry best practice is to revisit the diagnosis every 6 months, to assess if the client's current symptomatology and presentation still align with the DSM criteria for the stated diagnosis.  

 

Where do I update the diagnosis?

  • Each time you create a new progress note, you have the opportunity to enter any diagnosis you chose - whether it be the same from previous sessions, or a new one. You do not need to go back and change any prior documentation, however you DO need to add in clinical information in the body of the note that documents that you have changed the diagnosis, and clinical justification for the change. Additionally, it is considered best practice to update treatment plan goals, ensuring that there is a goal related to any new or changed diagnosis. 


If you have additional questions or support needs related to diagnosing, you can reach out to our clinical quality team at quality@rula.com. Therapist to therapist - we’re here for you!

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