Principal Diagnosis in Mental Health Coding

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Principal Diagnosis in Mental Health Coding

Determining the root of a client’s symptoms and ultimately providing them with a diagnosis is a complicated and detailed process. Mental health providers have to do it quite frequently as they work with all different types of people experiencing various conditions. In this field, the prioritization of the diagnostic process and the understanding of principle diagnoses in mental health are critical to providing quality client care.

This is not news to any seasoned mental or behavioral health provider. Providing top-of-the-line patient care should be any provider’s number one priority. So what is the importance of the diagnostic procedure, and what is a principal diagnosis in mental health?

The Importance of Diagnostic Procedure?

The diagnostic procedure is why any client/patient seeks professional help. When an individual has a stuffy nose or a cough, they contact their doctor so that an experienced person can diagnose them and set them on a path toward recovery. 

In mental health, the process is similar. The diagnostic procedure starts with a client coming to a provider for attention and care. The diagnostic procedure in mental health then moves to gather information surrounding the individual’s personal and family history, symptoms, and any other relevant information that could contribute to their mental health. 

Providers use an array of mental health examinations and evaluations that help them gain clear insight into the client’s wellbeing. The diagnostic procedure occurs prior to the treatment plan to ensure the patient is on the right track once treatment begins. A diagnosis is made by pairing symptoms, results of the evaluations, and other relevant details with a diagnosis within the Diagnostic and Statistical Manual of Mental Health Disorders, also known as the DSM. 

What is a Principal Diagnosis in Mental Health?

Clients and patients are not limited to one diagnosis. In many situations, there are coinciding diagnoses that impact the individual simultaneously. These diagnoses are broken down into tiers based on chief priority or impact. 

The diagnosis that takes top priority or is tied to the patient’s primary reason for seeking care is the principal mental health diagnosis. The principal diagnosis in mental health is usually the most apparent, presents with the most symptoms, or is most concerning to the individual. 

What is a Differential Diagnosis?

After a principal diagnosis in mental health is a differential diagnosis. Sometimes an individual has symptoms that overlap diagnoses. To ensure that a provider covers all of their bases during the diagnostic procedure, they are to make a list of differential diagnoses linked to the individual’s experience. They then work through this list to identify the most accurately representing the patient’s condition. 

What is a Comorbidity? 

If a patient comes in with a wealth of symptoms, there is no guarantee that every symptom will fall into one diagnostic bucket. When this happens, it is up to the provider to determine if the client has any mental health comorbidities present. After the provider has gone through their differential diagnostic list and identified a primary mental health diagnosis, they need to determine if any of the individual’s symptoms are equal to comorbidity or a coinciding condition. 

How to Bill Accurately for Multiple Diagnoses

If a client has multiple diagnoses, that needs to be documented accurately and billed precisely to protect your reimbursement. Errors in billing/diagnostic codes are a principal reason for claim denials. To ensure the billing process functions smoothly and accurately, providers need to adopt quality mental health billing software. 

Software designed specifically for mental health professionals is equipped with a comprehensive list of DMS diagnostic codes and enables providers to bill accurately. Quality software will allow you to sequence a client’s primary diagnosis in mental health along with any comorbidities to make sure your payment is secure.  The diagnostic process is a pillar of mental health care that ensures clients and patients end up on the right path of care. The software providers use should support each process and enable them to offer the best care possible to each and every patient while protecting their bottom line.



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