Dx of Adjustment Disorder for Inpt Hosp for SI

[skunky386]

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Hypothetical scenario about appropriate use of DSM diagnoses:

Is it appropriate to use a diagnosis of adjustment disorder w/ depressed mood for an individual who is hospitalized to the psych unit for SI and depression over the last 1w secondary to relationship/workplace stressors?

When would one ever be able to diagnose an adjustment disorder given that criteria E (once the stressor or its consequences have terminated the symptoms do not persist for more than an additional 6 months) implies that you can read into far into the future or are diagnosing an old condition?

Another question along similar lines...What diagnosis would you give to a homeless individual who says they have been depressed, suicidal, hopeless, worthless, lost wt, etc. for 2w secondary to getting kicked out of their homeless shelter, and then is completely better the second the case manager finds them a shelter that will accept them? Technically per their subjective report they meet criteria for MDD, so is that the most appropriate and CYA thing to diagnose them with and treat? or would you diagnose malingering or adjustment disorder?

 

[clausewitz2]

Hypothetical scenario about appropriate use of DSM diagnoses:

Is it appropriate to use a diagnosis of adjustment disorder w/ depressed mood for an individual who is hospitalized to the psych unit for SI and depression over the last 1w secondary to relationship/workplace stressors?

When would one ever be able to diagnose an adjustment disorder given that criteria E (once the stressor or its consequences have terminated the symptoms do not persist for more than an additional 6 months) implies that you can read into far into the future or are diagnosing an old condition?

Another question along similar lines...What diagnosis would you give to a homeless individual who says they have been depressed, suicidal, hopeless, worthless, lost wt, etc. for 2w secondary to getting kicked out of their homeless shelter, and then is completely better the second the case manager finds them a shelter that will accept them? Technically per their subjective report they meet criteria for MDD, so is that the most appropriate and CYA thing to diagnose them with and treat? or would you diagnose malingering or adjustment disorder?

Malingering is not a diagnosis. I would note my concerns about clear external gains and swift improvement in symptoms aligned with a change in those incentives and say you are concerned (if you are) about possible feigning of symptoms.

Why not diagnose unspecified depressive disorder and suicidal ideation?

 

[skunky386]

Malingering is not a diagnosis. I would note my concerns about clear external gains and swift improvement in symptoms aligned with a change in those incentives and say you are concerned (if you are) about possible feigning of symptoms.

Why not diagnose unspecified depressive disorder and suicidal ideation?

Thanks for your input clauswitz. I've been informed from an attending that some insurance companies deny/limit reimbursement if the patient's primary diagnosis upon discharge is coded as depression, unspecified, psychosis, unspecified, etc.

 

[clausewitz2]

Thanks for your input clauswitz. I've been informed from an attending that some insurance companies deny/limit reimbursement if the patient's primary diagnosis upon discharge is coded as depression, unspecified, psychosis, unspecified, etc.

So throw in SI (ICD-10: R45.81). It is a billable code. We certainly do a lot of that here on an inpatient basis and no one says boo about it not getting paid (and our care managers are not shy about bringing up that sort of thing!)

 

[winniehoney]

Thanks for your input clauswitz. I've been informed from an attending that some insurance companies deny/limit reimbursement if the patient's primary diagnosis upon discharge is coded as depression, unspecified, psychosis, unspecified, etc.

are you sure about this? I have heard that adjustment disorder is denied. However, I frequently see Unspecified schizophrenia spectrum disorder asa discharge diagnosis.

 

[clausewitz2]

are you sure about this? I have heard that adjustment disorder is denied. However, I frequently see Unspecified schizophrenia spectrum disorder asa discharge diagnosis.

I imagine adjustment disorder will be denied as that is a good reason for hospitalization, which is why I would not put that down. But unspecified (or otherwise specified without an actual specifier) + SI definitely gets paid on around here without too much trouble. Now, yes, if you try to keep someone for a month behind that you are not going to have much luck getting paid but the typical two day stay until case management does their thing is a different story.

 

[splik]

Thanks for your input clauswitz. I've been informed from an attending that some insurance companies deny/limit reimbursement if the patient's primary diagnosis upon discharge is coded as depression, unspecified, psychosis, unspecified, etc.

This is not true. Insurance companies will authorize fewer days for hospitalization if the diagnosis is less specific, and you are going to be more likely to capture greater reimbursement if the diagnosis is more specific (which is why you should always list the most specific diagnosis and all relevant diagnoses) but you should also be honest about the diagnosis. as mentioned above, you can list suicidal ideations or homicidal ideations as one of the diagnoses if relevant. Note that HI/SI cannot be the primary diagnosis as they aren't psychiatric codes (the primary diagnoses need to be F codes and SI and HI are R codes).

also you can bill for adjustment disorder, it depends on the insurance. as adjustment disorder is not a parity diagnosis, insurance companies do not have to pay for it, but you should always be as honest as you can with diagnosis, especially if you appreciate that putting a more serious diagnosis could have ramifications for someone in the future including their career, or ability to get life or disability insurance etc.

 

[Stagg737]

Malingering is not a diagnosis. I would note my concerns about clear external gains and swift improvement in symptoms aligned with a change in those incentives and say you are concerned (if you are) about possible feigning of symptoms.

Why not diagnose unspecified depressive disorder and suicidal ideation?

Where are you getting the bolded from? It's both in the DSM and is a billable ICD-10 code (Z76.5). Or did you just mean that malingering isn't a psychiatric condition?

 

[Taddy Mason]

Where are you getting the bolded from? It's both in the DSM and is a billable ICD-10 code (Z76.5). Or did you just mean that malingering isn't a psychiatric condition?

Z codes aren’t reimbursed.

 

[Stagg737]

Z codes aren’t reimbursed.

Didn't realize that. If you use CPT codes for billing you can still bill for malingering with a 99232 code though.

 

[splik]

Didn't realize that. If you use CPT codes for billing you can still bill for malingering with a 99232 code though.

you can bill for anything. The issue is reimbursement. many insurance companies will not reimburse for malingering because they will argue this is not "medically necessary". never mind that you had to do the evaluation to figure that out in the first place. which leaves the patient on the hook for the bill, and the kinds of patients that malinger are not going be paying their bills. luckily, most patients who malinger psychiatric symptoms will have a psychiatric diagnosis. Regardless, this should not concern us. Our billers sometimes suggest changing the diagnosis to something incorrect if the correct "diagnosis" is not going to be reimbursed. My response is always "you're not asking me to commit insurance fraud, are you?" cue radio silence. Luckily no one is looking at my rvus, but this is why if you do accept a production based position you want to do it based on RVUs billed rather than on collection.

 

[Stagg737]

you can bill for anything. The issue is reimbursement. many insurance companies will not reimburse for malingering because they will argue this is not "medically necessary". never mind that you had to do the evaluation to figure that out in the first place. which leaves the patient on the hook for the bill, and the kinds of patients that malinger are not going be paying their bills. luckily, most patients who malinger psychiatric symptoms will have a psychiatric diagnosis. Regardless, this should not concern us. Our billers sometimes suggest changing the diagnosis to something incorrect if the correct "diagnosis" is not going to be reimbursed. My response is always "you're not asking me to commit insurance fraud, are you?" cue radio silence. Luckily no one is looking at my rvus, but this is why if you do accept a production based position you want to do it based on RVUs billed rather than on collection.

You can make the same argument for plenty of other diagnoses or treatments other than malingering as well though (and you did). My biggest point was that malingering IS a diagnosis and you CAN bill for it and the original post I was responding to said it's not a diagnosis.

Last line is really good advice though and something I'd never even thought about.

 

[michaelrack]

I really hate it when someone diagnoses adj disorder AND then starts a ssri

 

[Taddy Mason]

You can make the same argument for plenty of other diagnoses or treatments other than malingering as well though (and you did). My biggest point was that malingering IS a diagnosis and you CAN bill for it and the original post I was responding to said it's not a diagnosis.

Last line is really good advice though and something I'd never even thought about.

Go ahead and bill for it, but keep your expectations for reimbursement low, if any at all.

 

[Stagg737]

Go ahead and bill for it, but keep your expectations for reimbursement low, if any at all.

Still doesn't change that it is an actual diagnosis.

 

[Crayola227]

Malingering is not a diagnosis. I would note my concerns about clear external gains and swift improvement in symptoms aligned with a change in those incentives and say you are concerned (if you are) about possible feigning of symptoms.

Why not diagnose unspecified depressive disorder and suicidal ideation?

I don't think they are necessarily feigning symptoms, lol. I've been homeless sleeping under a bridge before. What a difference it makes to not be in the rain. When you're on the street, sure, you get used to things, but most are never really singing in the rain if you get what I mean, at baseline. It doesn't take "much" to push you into slightly more truly genuine SI in those circumstances. Misery on misery. I say genuine SI, although it's anyone's guess if the SI is high risk or not, or needs hospitalization. Even though something as "simple" as being out of the rain with a source of food can really buck you up and make you less interesting in taking up a knife, none of this is necessarily just feigning anything for secondary gain. Certainly some lability involved. I guess this is way of saying, that just because secondary gain does exist, and that secondary gain can make you feel better, that doesn't mean it's just malingering, feigning, or about secondary gain.

Sometimes we forget how fundamentally threatening it is to the core of your being to have no money, shelter, food, safety, to be in physical pain, the feelings of desperation and desire for escape, and how quickly those feelings can abate when you restore the some of the base of Maslow's hierarchy.

 

[clausewitz2]

I don't think they are necessarily feigning symptoms, lol. I've been homeless sleeping under a bridge before. What a difference it makes to not be in the rain. When you're on the street, sure, you get used to things, but most are never really singing in the rain if you get what I mean, at baseline. It doesn't take "much" to push you into slightly more truly genuine SI in those circumstances. Misery on misery. I say genuine SI, although it's anyone's guess if the SI is high risk or not, or needs hospitalization. Even though something as "simple" as being out of the rain with a source of food can really buck you up and make you less interesting in taking up a knife, none of this is necessarily just feigning anything for secondary gain. Certainly some lability involved. I guess this is way of saying, that just because secondary gain does exist, and that secondary gain can make you feel better, that doesn't mean it's just malingering, feigning, or about secondary gain.

Sometimes we forget how fundamentally threatening it is to the core of your being to have no money, shelter, food, safety, to be in physical pain, the feelings of desperation and desire for escape, and how quickly those feelings can abate when you restore the some of the base of Maslow's hierarchy.

I mostly agree with you, which is why I suggested this be noted only if there was concern for it. By "feigning," I mean exaggerating or producing symptoms may not a way that is aligned closely with external incentives. Many people with undisputed psychiatric conditions will feign these symptoms at some point to get their needs met in a more timely or more complete fashion, so the person in the story above may well have entertained thoughts of suicide.

That said, if the threat of suicide was made in a clearly contingent manner ("if you don't admit me I'll kill myself") it does raise my priors on the person in question treating reported SI as a magical incantation for housing and food.

 

[whopper]

Malingering is not a diagnosis.

Depends on your definition. E.g. Polysubstance Abuse is not in the DSM, any of them.
It does, however, meet the English word definition of a diagnosis.

Malingering is in the ICD as a Z-code. It is a recognized phenomenon. It has hundreds+ of published articles about it.

Most argue you shouldn't put it down in the chart but that doesn't remove it as a potential diagnosis. Phil Resnick in his malingering lectures states that you shouldn't put it down unless you have solid evidence such as testing and detailed notes explaining why. Even then I'd recommend thinking more than twice about it because malingering has been argued to be a pathological character judgment on the part of the physician against the patient.

What I typically do if I had solid evidence to believe someone was malingering was write a dx of Adjustment Disorder with...sometimes a disturbance of conduct because it often does meet that definition.

 

[clausewitz2]

Depends on your definition. E.g. Polysubstance Abuse is not in the DSM, any of them.
It does, however, meet the English word definition of a diagnosis.

Malingering is in the ICD as a Z-code. It is a recognized phenomenon. It has hundreds+ of published articles about it.

Most argue you shouldn't put it down in the chart but that doesn't remove it as a potential diagnosis. Phil Resnick in his malingering lectures states that you shouldn't put it down unless you have solid evidence such as testing and detailed notes explaining why. Even then I'd recommend thinking more than twice about it because malingering has been argued to be a pathological character judgment on the part of the physician against the patient.

What I typically do if I had solid evidence to believe someone was malingering was write a dx of Adjustment Disorder with...sometimes a disturbance of conduct because it often does meet that definition.

Isn't malingering in the DSM V with "other conditions that may be the focus of clinical attention"? Almost definitionally, if someone's behavior is accounted for predominantly by a psychiatric condition or medical condition, they are not malingering.

I like Rogers and how he avoids pointless arguments about primary v secondary gain and emphasizes identifying observable external incentives and the extent to which they appear to be driving the presentation.

 

[Crayola227]

Isn't malingering in the DSM V with "other conditions that may be the focus of clinical attention"? Almost definitionally, if someone's behavior is accounted for predominantly by a psychiatric condition or medical condition, they are not malingering.

I like Rogers and how he avoids pointless arguments about primary v secondary gain and emphasizes identifying observable external incentives and the extent to which they appear to be driving the presentation.

This.

 

[NickNaylor]

Malingering is not a diagnosis. I would note my concerns about clear external gains and swift improvement in symptoms aligned with a change in those incentives and say you are concerned (if you are) about possible feigning of symptoms.

Why not diagnose unspecified depressive disorder and suicidal ideation?

I would argue that, if you're convinced the presentation is MDD, you could diagnosed other specified depressive disorder and state that the patient meets criteria for a major depressive episode with the exception of the time criterion.

Or call it an unspecified depressive disorder.

At some point it just becomes a bit of an academic circlejerk.

 

[Stagg737]

So here's a situation for the "malingering isn't a diagnosis/shouldn't be used" people:

Patient presents to ED with complaints that check off all SIG E CAPS criteria including SI with plan (which he is obviously lying about). After interviewing the patient for about an hour, they eventually admit that they have not been experiencing any of these symptoms other than some mild fatigue recently. Upon further questioning they straight up tell you they just wanted attention for a minor medical problem which is scheduuled to be completed in a month and he thinks that if he can get admitted to the hospital at all he can get it done sooner. He has also come to the ED 4 times in the past 2 weeks and attempted to do the same thing (evidenced by good documentation on 2 of the previous visits).

What's your diagnosis?

 

[clausewitz2]

So here's a situation for the "malingering isn't a diagnosis/shouldn't be used" people:

Patient presents to ED with complaints that check off all SIG E CAPS criteria including SI with plan (which he is obviously lying about). After interviewing the patient for about an hour, they eventually admit that they have not been experiencing any of these symptoms other than some mild fatigue recently. Upon further questioning they straight up tell you they just wanted attention for a minor medical problem which is scheduuled to be completed in a month and he thinks that if he can get admitted to the hospital at all he can get it done sooner. He has also come to the ED 4 times in the past 2 weeks and attempted to do the same thing (evidenced by good documentation on 2 of the previous visits).

What's your diagnosis?

What's the nature of the medical problem? Illness anxiety disorder or something in the somatic family seems like a good bet for dx. I would also definitely note my concerns that his suicidal statements seemed to be contingent and/or instrumental and aimed at securing medical attention. Also of course you write down that he told you that explicitly.

If someone says they're lying, then obviously saying they are malingering is much easier. But of course it is not a necessary or sufficient condition; plenty of people with genuine SI have enough ambivalence that they might say they were lying a couple days into admission in order to be released. Collateral is vital if at all available.

 

[Stagg737]

What's the nature of the medical problem?

Hemorrhoids. Scheduled to have them removed in December but wants them out right now. I don't think IAD would be appropriate in this case as his complaints are specific and the ones that are more vague/inaccurate he openly admitted he made up. I honestly don't know what else his diagnosis would be other than malingering. Collateral provided by his son who lives with him and confirms that there is indeed nothing wrong with this patient and that he is manipulating the system to try and get his already scheduled procedure done sooner. I mean, he very well may have a personality disorder, but I wasn't about to refer this guy for neuropsych testing based on a single ED consult.

 

[clausewitz2]

Hemorrhoids. Scheduled to have them removed in December but wants them out right now. I don't think IAD would be appropriate in this case as his complaints are specific and the ones that are more vague/inaccurate he openly admitted he made up. I honestly don't know what else his diagnosis would be other than malingering. Collateral provided by his son who lives with him and confirms that there is indeed nothing wrong with this patient and that he is manipulating the system to try and get his already scheduled procedure done sooner. I mean, he very well may have a personality disorder, but I wasn't about to refer this guy for neuropsych testing based on a single ED consult.

I am puzzled about why neuropsychology testing would be in order to assess for a personality disorder. What did you have in mind?

I think a critical piece would be to figure out why he felt it couldn't wait. I know that takes more time to suss out in interview but I would argue it is necessary here to understand what is going on. There is clearly an external incentive of sorts but most people do not find it hard to wait for hemorrhoid surgery - this is a strange behavior. Does he does this in any other spheres of his life?

Malingering really doesn't explain much about this situation. In an ED consult, I get it, time is limited, but you have to bear in mind that you are missing a lot and it is a little too easy to dismiss the whole case when malingering gets used as a dx.

 

[splik]

Hemorrhoids. Scheduled to have them removed in December but wants them out right now. I don't think IAD would be appropriate in this case as his complaints are specific and the ones that are more vague/inaccurate he openly admitted he made up. I honestly don't know what else his diagnosis would be other than malingering. Collateral provided by his son who lives with him and confirms that there is indeed nothing wrong with this patient and that he is manipulating the system to try and get his already scheduled procedure done sooner. I mean, he very well may have a personality disorder, but I wasn't about to refer this guy for neuropsych testing based on a single ED consult.

it's not malingering if they tell you they were making it up. and neuropsychological testing would not be indicated for the evaluation of personality disorder. did you mean psychological testing? even then, a good semi-structured clinical interview and collateral information would be more instructive.