Wiki Behavioral Health Dx Coding

[KayOverbey]

I work for a residential mental health facility. We have licensed therapists and one psychiatrist who comes in once a week to do evaluations/med management.

The therapists perform an initial assessment when they arrive, and give them a diagnosis. Then the psychiatrist visits with them, it may be a few days depending what day they are admitted here.

The therapists believe that once the psychiatrist diagnosis them, the diagnosis they gave on the initial assessment is null and void. This doesn't seem right to me, as every encounter should be a separate one, and the documentation should compliment the diagnosis. Typically, the diagnosis are the same. Sometimes the therapists will have more than one diagnosis, but when the doc comes in he only documents one of the three that were previously given.

This is my first position in a behavioral health facility, but I am reviewing DSM V and I can't find any indication that the psychiatrists' diagnosis trumps the therapists. Not to mention, when they give me their weekly logs for therapy visits, the diagnosis from the initial assessment is what they list. So it's a little contradicting.

Any insight would be GREATLY appreciated!!

 

[Amy Pritchett]

The diagnosing is not a "trump" issue. When the therapist sees the patient for the initial evaluation, are they filing under their NPI or the NPI of the practicing physician?
If you are filing for reimbursement under the therapist for the initial visit, then their findings at the time of the assessment would be your diagnosis code for the initial visit only.
When the physician sees the patient, then you would file a claim under their NPI with the formal diagnosis code that is given at the time of the encounter/admission.

Hope this helps

 

[KayOverbey]

The diagnosing is not a "trump" issue. When the therapist sees the patient for the initial evaluation, are they filing under their NPI or the NPI of the practicing physician?
If you are filing for reimbursement under the therapist for the initial visit, then their findings at the time of the assessment would be your diagnosis code for the initial visit only.
When the physician sees the patient, then you would file a claim under their NPI with the formal diagnosis code that is given at the time of the encounter/admission.

Hope this helps

Yes, Amy. This helps tremendously. We are filing under the therapists' NPI for the initial assessment, and the physician's assessment under his NPI. So this part I know we are doing correctly. It's for any therapy visits following the physician's assessment that we are a little confused about. Do we use the physician's diagnosis for the therapy visits going forward?

Again, thanks for the help!