Social Science - Sociology Assignment 3

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Red Flags and Their Key Words

When evaluating clients, be aware of what is being said, what is unspoken, and any nonverbal messages the client is sending. There are certain words mentioned by a client that may lead you to evaluate for certain disorders first, and then followed by evaluating the differential diagnosis. Below are some words—i.e., “red flags”—to help you evaluate for certain disorders. You still need to be open to other possibilities, but this will give you a place to start.

Schizophrenia and Other Psychotic Disorders

I hear people talking to me. They are telling me . . . They are after me. Client’s speech does not make sense.

Bipolar I’m on top of the world. I bought all this stuff. I do not need much sleep. Client’s speech is very fast

Depressive Disorders I am depressed. I do not want to go out anymore. I do not want to wake up. I cannot sleep. I am so tired. I gained weight recently. I lost weight recently. I cannot concentrate.

Anxiety Disorders I worry about everything. I am up at night thinking. I have anxiety attacks. I panicked out of nowhere.

Obsessive compulsive disorders I worry about the dirt in my house. My thoughts go round and round. I do repetitive behaviors. I have repetitive thoughts.

Trauma and Stressor-Related Disorders I am easily startled. I have nightmares. I do not want to talk about the situation. I no longer go to those places. I avoid those people.

Dissociative Disorders I have gaps in my memory. “We”. . . “They”. . .

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Tips and Guidelines for Practice Diagnosis in This Course

Consider printing this tip sheet. Keep it next to you as you work through each practice diagnosis.

Remember: After the intake assessment, you must make a diagnosis. In this course, the details you would normally observe and assess are found in the written case study that you read. With the case studies, apply the criteria in an applicable assessment measure to gauge symptoms and severity based on details in a case study.

Also, utilize the resources in the course, such as the American Psychiatric Association’s Online Assessment Measures (see the online classroom for the most up-to-date link). For these, you would use an applicable questionnaire to guide an interview and follow the guidance within each assessment measure.

When diagnosing, place the diagnosis (i.e., the diagnostic code—F followed by the number and disorder name) before your summary. It must look like this:

F33.3 Major depressive disorder, recurrent episode, with psychotic features

F42 Obsessive-compulsive disorder, with poor insight

F10.20 Alcohol use disorder, in sustained remission Z56.9 Other problem related to employment Z60.9 Unspecified problem related to social environment

Other Tips

1. ICD 10 codes MUST be used (e.g., F60.90). 2. Z codes must be added. These are psychosocial and environmental stressors

impacting the case over the last 12 months. 3. Cases may include any diagnoses previously covered in earlier weeks. 4. Look for all possible diagnoses for the case, not just those related to the readings

for the week. o No cases will include diagnoses that have not been covered in earlier

weeks. 5. Differential diagnosis means the case has similar symptoms—it does not mean

compare any case in the DSM-5-TR. 6. When explaining your decision in the summary portion please include the criteria

in the case that refer to the symptoms you are noting. 7. Read the directions in the course.

Other Specified and Unspecified Diagnosis

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Other Specified and Unspecified Diagnosis

Program Transcript NARRATOR: You gather information from a client to diagnose during an intake. What

happens if the client does not meet the required symptoms to make the diagnosis? It

might have feeling tentative about what to diagnose. You may have heard or seen

tentative, provisional, or rule-out diagnoses. Those terms may describe your

uncertainty, but do they have a place and a diagnosis?

The answer is a simple no for social workers. Some agencies utilize these terms after

they code a diagnosis. Although, for best practice, you are strongly advised to avoid

them. You'll see why soon. But first, let's focus on the best practice, using other

specified or unspecified.

In real-world settings, be prepared for clients who do not meet every required symptom

of a disorder. A client may arrive with depression, lethargic, and experiencing a loss of

pleasure or interest. They report a diminished ability to concentrate. These are some

criteria for major depressive disorder. But to diagnose a depressive episode, you need

five of the nine listed symptoms. And right now, you only have three. At this point, you

cannot legitimately diagnose major depressive disorder.

Still, your detective skills point you strongly in this direction. How do you diagnose? In

every category of the DSM-5-TR, there are two options called other specified and

unspecified disorders. Both mean the client does not meet the full criteria for a disorder.

First, let's explore other specified disorder, which means the client is suspected to be in

this category, but the full criteria are not met, despite showing some symptoms. You are

diagnosing this fact and documenting the reason for the full disorder is not met, in this

case, not meeting five out of the nine symptoms. You must record the name of the

category followed by the specific reasons. F32.89 is the code for other specified

depressive disorder followed by a comma, followed by the reason why they don't meet

the criteria.

You can also use unspecified disorder, also an option in every category. Here, you do

not need to say why certain criteria are not met, while still recording a diagnosis that is

acceptable. Note that the number code is different in each of these. These are

legitimate diagnoses, and they are covered by insurance.

Other Specified and Unspecified Diagnosis

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Why should you not use tentative, provisional, or a rule-out diagnosis when you don't

have all the criteria, even if an agency would allow it? There is no code that

corresponds to the words tentative, provisional, or rule out. Using these as if they are

implied from codes, is essentially saying the client meets the criteria for a disorder.

Note the difference between the provisional code and the other specified code. One

code records a specific disorder that may not be present. It may be recorded on records

without the provisional noted, which could be confusing or ultimately inaccurate. When

the code is submitted to insurance companies, there is not a spot for the word

provisional, and sometimes just the code itself may appear on a form. So the insurance

accepts this as the client's diagnosis when they never fully met the criteria, except, as

we noted, we're not fully sure it's major depressive disorder yet.

The other specified code is in its own unique code that accounts for how the client

actually presents. Using other specified and unspecified diagnoses are the best ways to

still work within the parameters of proper diagnoses, but account for the reality of a

complex process. They allow you to be accurate while you continue evaluating the client

for the best treatment.

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How to Write a Diagnosis According to the DSM-5-TR

Writing a Diagnosis

A diagnosis is written as a simple list in order of priority to the current treatment needs. For example:

F33.1 Major depressive disorder, moderate, recurrent, with seasonal pattern F41.1 Generalized anxiety disorder Z60.3 Acculturation difficulty

Note: Each diagnosis needs a code that is written before the name of the diagnosis.

How to Code

A diagnostic code, even when using the DSM-5-TR, follows the ICD-10 code structure. The code structure is between three (3) and seven (7) characters. The figure below shows how each digit in the code is organized.

Alpha (Not U) Numeric Characters 3–7 can be any combination

of alpha or numeric

1st digit

2nd digit

3rd digit • 4th

digit 5th digit

6th digit

7th digit

Category Etiology, anatomical site, severity Extension

For mental health conditions, codes always start with a letter F, followed by two to six (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-TR. 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 and severity. For example, here are two codes for mania:

F31.11 Bipolar I disorder, current episode manic, mild

2

F31.13 Bipolar I disorder, current episode manic, severe

Many disorders have more than one ICD code when there are common and 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.

Coding note: Include the name of the medical condition in the name of the mental disorder (e.g., F06.1 catatonic disorder due to hepatic encephalopathy). The other medical condition should be coded and listed separately immediately before the catatonic disorder due to the medical condition (e.g., K72.90 hepatic encephalopathy; F06.1 catatonic disorder due to hepatic encephalopathy).

Now the diagnosis looks like this:

F25.0 Schizoaffective disorder, bipolar type 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.

How to List Multiple Codes

Formal DSM-5-TR diagnosis combines into one list all relevant mental disorders, including personality disorders. The DSM-5-TR also expands the psychosocial stressors that a patient might be experiencing. These are called “Other conditions that may be a focus of clinical attention” and most begin with the letter “Z.”

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These conditions, which are critical to psychosocial treatment, are found near the end of 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 comorbid diagnoses follow in order of priority to the treatment or focus of attention.

RULE A: In this diagnostic list, a mental disorder was the reason for the visit. Other psychosocial factors relevant to the service are listed after mental health conditions

F40.00 Agoraphobia Z60.3 Acculturation difficulty Z72.0 Tobacco use disorder, mild (nicotine use)

The order of priority above is (a) principal mental health diagnosis, (b) psychosocial needs.

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, 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)

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References

American Psychiatric Association. (2022a). Diagnostic and statistical manual of mental disorders (DSM-5-TR) (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787

American Psychiatric Association. (2022b). DSM-5-TR online assessment measures. https://www.psychiatry.org/psychiatrists/practice/dsm/educational- resources/assessment-measures

Centers for Disease Control and Prevention. (2017). ICD-10-CM official guidelines for coding and reporting: FY 2017 (October 1, 2016–September 30, 2017). https://www.cdc.gov/nchs/data/icd/10cmguidelines_2017_final.pdf

Centers for Disease Control and Prevention. (2022). International classification of diseases, tenth revision, clinical modification (ICD-10-CM). Retrieved from https://www.cdc.gov/nchs/icd/icd-10-cm.htm

CMS.gov. (2021). Provider resources. https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/ProviderResources

World Health Organization. (2022). ICD-11: International classification of diseases for mortality and morbidity statistics: Reference guide (11th ed.). https://icdcdn.who.int/icd11referenceguide/en/html/index.html