Find comprehensive information on DSM-5 Mental Disorders (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition), including diagnostic criteria, clinical documentation guidelines, and medical coding for DSM-V diagnoses. This resource supports healthcare professionals in accurate mental health assessment and treatment planning. Learn about DSM-5 diagnostic categories, differential diagnosis, and best practices for clinical documentation to ensure proper medical coding and billing.
Also known as
Mental, Behavioral, and Neurodevelopmental disorders
Covers a wide range of mental health conditions like schizophrenia, mood disorders, and anxiety.
Factors influencing health status and contact with health services
Includes reasons for encounters related to mental health like counseling and medication management.
Maltreatment syndromes
Captures maltreatment which can be a factor in or consequence of some mental disorders.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the disorder Neurodevelopmental?
Yes
Intellectual Disability?
No
Schizophrenia Spectrum?
When to use each related code
| Description |
|---|
| Classifies mental disorders. |
| ICD-10 mental and behavioral disorders. |
| Older, 4th ed. of DSM. |
Coding unspecified mental disorders (e.g., using NOS codes) when a more specific DSM-5 diagnosis is documented, impacting reimbursement and data accuracy.
Failure to accurately capture all present and documented mental health conditions, leading to undercoding and missed CC/MCC capture.
Insufficient documentation to support the medical necessity of the diagnosed mental disorder, potentially resulting in claim denials and compliance issues.
Q: How can I differentiate between DSM-5 Major Depressive Disorder and Persistent Depressive Disorder (Dysthymia) in clinical practice?
A: Differentiating between Major Depressive Disorder (MDD) and Persistent Depressive Disorder (PDD), previously known as Dysthymia, requires careful assessment of symptom duration and severity. MDD is characterized by at least one major depressive episode lasting a minimum of two weeks, presenting with symptoms like depressed mood, loss of interest, sleep disturbances, appetite changes, fatigue, and difficulty concentrating. PDD, on the other hand, involves a chronically depressed mood lasting for at least two years in adults (one year in children and adolescents), with at least two additional symptoms such as appetite changes, sleep disturbances, low energy, low self-esteem, poor concentration, or feelings of hopelessness. While MDD episodes are distinct and may remit, PDD presents as a more persistent, lower-grade depression. A key distinction is that MDD can have periods of normal mood between episodes, while PDD does not. However, individuals with PDD can experience superimposed major depressive episodes, sometimes referred to as "double depression." Accurate differential diagnosis is crucial for effective treatment planning. Explore how symptom timelines and severity impact treatment strategies for depressive disorders in the DSM-5.
Q: What are the key diagnostic criteria for Generalized Anxiety Disorder (GAD) according to the DSM-5, and how can I apply them effectively in a diagnostic interview?
A: According to the DSM-5, the diagnosis of Generalized Anxiety Disorder (GAD) requires excessive anxiety and worry, occurring more days than not for at least six months, about a number of events or activities. Clinically significant distress or impairment in social, occupational, or other important areas of functioning must also be present. The individual finds it difficult to control the worry, and the anxiety and worry are associated with at least three of the following six symptoms (with at least some symptoms having been present for more days than not for the past six months): restlessness or feeling keyed up or on edge; being easily fatigued; difficulty concentrating or mind going blank; irritability; muscle tension; and sleep disturbance. During a diagnostic interview, explore the specific content of worries, their frequency, duration, and the patient's ability to control them. Inquire about associated symptoms and their impact on daily functioning using specific examples. Consider implementing standardized anxiety rating scales to supplement clinical judgment and enhance the accuracy of the assessment. Learn more about utilizing validated assessment tools for anxiety disorders.
Patient presents for evaluation of mental health concerns. Presenting problems include (list specific symptoms e.g., depressed mood, anxiety, insomnia, difficulty concentrating, changes in appetite, suicidal ideation if present). Duration of symptoms is reported as (duration). Onset of symptoms is described as (onset - e.g., gradual, sudden, related to a specific event). Review of systems includes (pertinent positive and negative findings related to mental health, e.g., sleep disturbance, changes in weight, fatigue, lack of energy, feelings of hopelessness, worthlessness, or guilt). Past psychiatric history includes (previous diagnoses, treatments, hospitalizations). Family history of mental illness is (positive or negative, specifying disorders if positive). Substance use history includes (current and past use of alcohol, tobacco, illicit substances). Medical history is significant for (relevant medical conditions). Current medications include (list all medications). Allergies include (list all allergies). Mental status examination reveals (objective findings, e.g., appearance, behavior, mood, affect, speech, thought process, thought content, cognition, insight, judgment). Provisional diagnosis based on DSM-5 criteria is consistent with (specific DSM-5 diagnosis, e.g., Major Depressive Disorder, Generalized Anxiety Disorder, specifying severity and specifiers if applicable). Differential diagnosis includes (other potential diagnoses considered and ruled out). Treatment plan includes (psychotherapy - specifying type, e.g., Cognitive Behavioral Therapy, medication management if applicable, specifying medication and dosage, patient education, referral to other healthcare professionals if necessary, safety planning if indicated). Patient education provided regarding the nature of the diagnosis, treatment options, potential side effects of medications, and the importance of follow-up care. Follow-up appointment scheduled for (date). Prognosis is (guarded, fair, good) based on patient presentation, history, and planned treatment. This documentation supports the medical necessity for diagnostic evaluation and treatment of DSM-5 mental disorders using appropriate ICD-10-CM diagnostic codes for billing and coding purposes. The information provided in this note adheres to clinical documentation guidelines for mental health services.