Search

Sunday, April 21, 2019

Coding Medical Conditions


Making the MindBody Connection

By: SOPHIA F. DZIEGIELEWSKI

In using the DSM-5, several issues need to be explored. Perhaps most important is  remembering the importance of linking the mind and the body. People are complex beings. When a categorical approach to identifying and classifying disorders is utilized, the temptation is great to apply concrete and discrete criteria that do not include the full range of an individuals existence or situation.

Adding the concepts of the dimensional assessment and crosscutting of symptoms enables considering a greater range of symptomology without a formal diagnosis. It also allows factors related to another medical condition to be considered.

Making the connection between mind and body and studying the resulting relationship is crucial to a comprehensive diagnostic assessment. A medical disorder can clearly affect individual functioning, and vice versa. The medical disorder and its subsequent symptoms as reported by the client can easily become confused. Just having a medical disorder can affect the mental disorder, which in turn can influence the course of many diseases leading to short-term or long-term disability.

In addition, mental health conditions can influence other medical conditions, such as cardiovascular disease, diabetes, HIV/AIDS, tuberculosis, and malaria. According to Prince et al. (2007), mental health conditions and the behaviors that are characteristic can influence reproductive and sexual health with the development of conditions such as dysmenorrhea (disturbed menstrual cycles) and dyspareunia (genital pain during intercourse and other sexual activities).

In professional practice, it is easy to see how the line between what constitutes good physical health and what constitutes good mental health might be blurred (Dziegielewski, 2010). Separating the mind from the body is impossible, and the concept of wholeness must be considered. Achieving healthy outcomes requires positive and healthy mental health, and vice versa.

Integrating these medical components into diagnostic assessment can increase the application of this connection. For example, for a client who has all the symptoms of depression but was recently diagnosed with cancer, a mental health diagnosis of this nature could be premature if not simply inaccurate. A diagnosis alone is never enough, and each practitioner must also assess a situation completely, taking into account system variables that include a persons physical health.

The DSM-5 no longer uses the multiaxial diagnostic system that was previously clearly delineated and coded on Axis III; however, listing a medical condition still remains relevant when it affects or compounds the mental health diagnosis. Listing a medical condition remains relevant when the mental disorder appears to have a physiological relationship or bearing on the mental health diagnosis listed.

It is also important to note when the medical condition actually causes, facilitates, or is part of the reason for the development and continuation of the mental health condition. In this situation, according to the ICD, the medical condition that causes the mental health condition would be listed first as the reason for visit.

One sure way to establish whether the medical condition is the reason for visit is when the relationship between the medical and mental disorder is such that when the medical condition is resolved, the mental health condition is resolved as well.

This premise sounds easy to the beginning professional, but for those more experienced, it is clear this simple distinction is not always so simple. Although conclusive, this relationship can be complicated, and there is often no simple pathway, especially when the damage from the general medical condition may not be curable.

Regardless, it is important to document all related medical conditions that are important or can influence forming the mental diagnosis (APA, 2013). (See Quick Reference 3.15.) For the coding and specific categories of such disorders, see the ICD-10 and most probably after 2015 the ICD-11.

QUICK REFERENC Quick Reference 3.15E 3.15
General Categories for Medical Diseases and Conditions
Diseases of the nervous system
Diseases of the circulatory system
Diseases of the respiratory system
Neoplasms
Endocrine diseases
Nutritional diseases
Metabolic diseases
Diseases of the digestive system
Genitourinary system diseases
Hematological diseases
Diseases of the eye
Diseases of the ear, nose, and throat
Musculoskeletal system and connective tissue diseases
Diseases of the skin
Congenital malformations, deformations, and chromosomal abnormalities
Diseases of pregnancy, childbirth, and the puerperium
Infectious diseases
Overdose
Additional codes for the medication-induced disorders
*ICD medical codes are no longer listed in DSM-5.
Source:
List of topics reprinted with permission from the Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition, Text Revision
, Copyright 2000 by the American Psychiatric
Association.

When assessing medical conditions, non-medically trained mental health practitioners may find it helpful to receive support from an interdisciplinary or multidisciplinary team that includes medically trained professionals (Dziegielewski, 2013). Individuals who have training in the medical aspects of disease and illness can be valuable resources in understanding this mindbody connection. (See Quick Reference 3.16.)

QU Quick Reference 3.16ICK REFERENCE 3.16
Important Questions in Assessing Medical Symptoms
Has the client had a recent physical exam? If not, suggest that one be ordered.
Does the client have a summary of a recent history and physical exam that can be reviewed? If not medically trained, does the practitioner have someone to consult and review these with?
Be sure to examine whether the etiology could be medically related.
Are there any laboratory
findings, tests, or diagnostic reports that can assist in establishing a relationship between the mental and physiological consequences that result? If not medically trained in this area, does the practitioner have someone medically trained to consult or refer?

When medical conditions are listed and recorded as part of the diagnostic assessment, there should always be hard evidence to support its inclusion. The practitioner should query whether a recent history and physical exam has been conducted and, when one is available, review the written summary, which can be helpful in identifying medical conditions that may be related to the symptoms and behaviors a client is exhibiting.

As stated earlier, if a physical exam has not been conducted prior to the assessment, it is always a good idea to refer the client for a physical or suggest that the client see a physician for a routine examination. A review of the medical information available, such as lab reports and other findings, as well as consulting with a medical professional, may be helpful in identifying disorders that could complicate or prevent the client from achieving improved mental health.

When looking specifically at the relationship between the mental and the medical disorder, mental health practitioners should be prepared to inquire into the signs and symptoms of these conditions and to assist in understanding the relationship of this medical condition to the diagnostic assessment and the planning processes that evolve.

References

SOPHIA F. DZIEGIELEWSK, 2015, DSM-5TM in Action, by John Wiley & Sons, Inc.

Read Also



No comments:

Post a Comment