Determining order of Axis I diagnoses, if it matters at all.

[imnotdavid]

So I am currently working with a county mental health clinic that assesses criminal defendants and determines whether they are right for a mental health diversion program. Basically, our diagnoses determine whether a client will go to prison or will get to complete a year long mental health program instead.

In our program, sometimes we have dual diagnoses of, for example, alcohol use disorder and schizophrenia.

The way our program works, if we list under Axis I, "alcohol use disorder, schizophrenia" then our client is not suitable for the program and goes to prison because the drug problem was listed first. However, if we switch the order and list under Axis I, "schizophrenia, alcohol use disorder" then the client is eligible for further assessment.

I've never heard of this before...the order of Axis I diagnoses having meaning. What is the authority on this?

And if the order does make a difference, how do you determine which goes first? For example, we had a client who was in jail for 3 months and so he obviously had no alcohol for at least 3 months. But another clinician gave him "alcohol use disorder, schizophrenia (or bipolar - I can't remember at the moment)" and so he was rejected from the program. How did they determine to list alcohol use first, given those circumstances?

So confused. Please help =/

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[erg923]

First, when are you transitioning to DSM-5, in which there is no more Axis system? It been out for almost 2 years now.

Historically, the chief/primary diagnosis goes first. This is explicitly stated in the DSM-IV.

I'm not sure why such an arbitrary clerical issue is being used as cutting point for person's life. This sounds like an obvious systemic problem that should be addressed in your program. Moreover, the notion that diagnosis alone should shape something as impactful as medical treatment vs incarceration is idiotic and should also be addressed by your clinical admins.

 

[Goobernut]

Like Erg said, no more axis anymore anyway. Some agencies have not yet caught up with that. If I had a nickel for every time someone said "I bet this patient has an axis II diagnosis" after the DSM-5 was implemented, I'd be rich haha.

As far as I know, the only place that order sometimes makes a difference is on insurance claims. Knowing the rules of your system, basically all you can do is order them in a way that best reflects the needs of the patient. I can only guess on the motivation of your colleague. Just keep in mind that some (NOT ALL) people who work in and around the prison system can sometimes be jaded. Sometimes you are working with such limited funds and resources that there has to be a cut-off.

You'll find that within systems (VA, Medicare, Indian Health) the systems will make rules surrounding diagnostic and procedural codes that do not follow "coding best practices." However, they have determined that within that system, that's how it will be done. It's not illegal, or fraud, as long as you are following the rules within that system.

In short? There could be tons of reasons the other professional did what they did. For your dilemma of which to put first, I'd talk to others at your work/internship/practicum and see what their system is, but my personal suggestion (with the small part of the story you have given here) is to be thorough with your evaluations and list what diagnosis first you think will be most beneficial to the patient's needs (not just wants, but needs).

 

[AcronymAllergy]

To be fair, even with folks switching over to DSM5, the "axis II issues" phrase still obviously has meaning. Same goes with, "I sense some serious cluster B going on."

As for my own reports, I'll typically list the various diagnoses in the order that I feel they are contributing to the referral question (typically re: cognitive dysfunction).

And I agree with erg--using the ordering of diagnoses in a report as a means of determining eligibility for a treatment program seems, to me, to be rather arbitrary and inappropriate.

 

[imnotdavid]

Thank you for the replies. I tend to agree that the ordering seems arbitrary and inappropriate, but my credentials aren't really enough to cause any waves.

I am scouring the net for a published paper which supports my opinion. Are any of you aware of a paper on this topic?

Unfortunately I don't think there's much that I can do about using the old DSM IV at the moment. But if I can show that the DSM IV is not being applied properly, that might make a difference.

 

[Goobernut]

To be fair, even with folks switching over to DSM5, the "axis II issues" phrase still obviously has meaning. Same goes with, "I sense some serious cluster B going on."

To be fair to me... I didn't say that the phrase had no value or make judgements about people who still use that language. I was just stating the language was outdated. Like around here people still use "EOD." Even though the language changed to "ED" many years ago, I know what they are talking about.

Also don't clusters still exist? So that's not outdated? Or am I really confused? Did they change them up?

And yes OP, coding of all kinds is arbitrary. You get enmeshed in one system and you don't realize how arbitrary and system dependent it is until you move to another. You can tell your system that they are not following national coding initiatives and they won't care because they are using the codes "in-house." It is also perfectly legal. As long as it's all in-house. And the definition of what is in-house is also oftentimes complex.

If you really want to change the reporting process, you will have to demonstrate how/why the current process results in money losses or demonstrate how the current rules being applied inconsistently and result in poor program service. I say this because of my personal experience in billing/coding/reimbursement analyst positions.

 

[imnotdavid]

That's great feedback, Goobernut. Thank you.