Module #7: Diagnoses

Contents

• 7.1 Overview
• 7.2 MH and AODA Diagnoses
  • A Diagnosis is Required for Eligibility
  • Who Can Make MI/AODA Diagnoses
  • Where Screeners Obtain Diagnoses
  • Not all Diagnoses are Included in the MH/AODA FS
  • Multiple Diagnoses Over Time
  • Summary of MH/AODA Diagnoses
• 7.3 Global Assessment of Functioning (GAF)
• 7.4 "Other Diagnoses" Table
  
  

7.1 Overview

There are two diagnoses tables on the MH/AODA FS. The first is for mental illness and substance-related diagnoses, and the second is to indicate other general medical diagnoses. Psychiatric diagnoses are needed for eligibility for MH programs. "Other" or "general" medical diagnoses do not affect eligibility for MH/AODA programs. The "other" diagnoses are included on the MH/AODA FS to improve, at all levels from practitioners' awareness to county and state systems, the well-being and access to quality health care for people with mental illness and/or substance use problems.

[Back to Top]

7.2 MH and AODA Diagnoses

The MH/AODA FS reflects current state and federal policies on eligibility for Medicaid-funded MH and AODA programs. As those policies evolve (e.g., with the new CCS program), the functional screen and instructions will be revised as needed.

A Diagnosis is Required for Eligibility

• Specific psychiatric or AODA diagnoses are required for eligibility for most MH or AODA programs (respectively) in Wisconsin.
• Nicotine addiction is listed but does not count toward eligibility for AODA treatment programs.
• For MH programs, the applicant must have at least one of the specified psychiatric diagnoses listed in this table, including the precise numeric code from the DSM-IV (Diagnostic and Statistical Manual - Version 4).

[Back to Top]

Who Can Make MI/AODA Diagnoses

• Psychiatric diagnoses must have been made by a psychiatrist or licensed psychologist.
• Non-psychiatrist MD's diagnoses are NOT sufficient for eligibility for MH programs.
• Psychiatric nurse practitioners' or physician's assistants' diagnoses do count if made under supervision of a psychiatrist.
• AODA diagnoses checked in the functional screen should reflect diagnoses made by professionals whose scope of practice includes diagnosing substance use disorders (physicians, advanced practice nurses, psychiatrists, and some AODA professionals).

[Back to Top]

Where Screeners Obtain Diagnoses

Screeners can obtain diagnoses from any of the following:

• Written records from psychiatrist or licensed psychologist.
• Other medical records if the psychiatric diagnosis was made by a psychiatrist or licensed psychologist.
• A healthcare or mental health professional's verbal report that a qualified professional made a particular diagnosis.
• Documentation from schools or group homes do not count unless they cite a diagnosis made by qualified diagnostician. In other words, school category assignments or diagnoses made by teachers do not count.
• Consumer or family report count if and only if they can state the diagnosis exactly and can name the qualified professional who made the diagnosis and (approximately) when.

Diagnoses obtained in these ways are "verified" diagnoses. In many cases, screeners will need to obtain a signed release of information in order to verify diagnoses. Sometimes you or another helper will need to persuade the consumer and assist them to see a qualified diagnostician to obtain the diagnoses required for entry into MH or AODA treatment programs.

[Back to Top]

Not all Diagnoses are Included in the MH/AODA FS

Not every diagnosis is considered sufficient grounds for eligibility for MH/AODA programs. The DSM-IV includes some diagnoses that should not count toward eligibility for MH/AODA programs. Examples include mental retardation, learning disorder, ADHD (attention deficit/hyperactivity disorder), or dementia.

If you encounter someone with a diagnosis not on this table whom you think should be eligible for MH/AODA programs, please contact your Screen Leader immediately, who will contact designated state staff.

[Back to Top]

Multiple Diagnoses Over Time

The same individual may be given different diagnoses by different psychiatrists at different times. Below are some guidelines to follow. These apply to psychiatric diagnoses made by psychiatrists or licensed psychologists only; diagnoses made by general MDs or others are not included in the MH/AODA Diagnoses table.

• Diagnoses do not have to be from within the past year if they still seem applicable.
• In general, use the most recent diagnoses.
• When the individual received different diagnoses at different times, you have two choices:

1. Check only the most recent diagnoses if earlier diagnoses seem no longer accurate or applicable.
   
   Example: Paula was diagnosed with schizophrenia at age 17, but records indicate that her current psychiatrist considers that a misdiagnosis, and that Paula has PTSD, cyclothymic disorder, and dissociative disorder. You do not check schizophrenia on the MH/AODA FS.
   
   
2. Check all the diagnoses if you're not sure which are the most accurate or whether or not they still apply.
   
   Screeners are not expected to make clinical decisions about whether or not a diagnosis is accurate or still applicable for an applicant. When you are not sure, go ahead and check the diagnosis in the table.
   
   Example: Tony has a long list of diagnoses from encounters with psych hospitals and psychiatrists in numerous states, including schizophrenia, schizophreniform disorder, schizoid personality disorder, bipolar disorder, anxiety, psychosis NOS (not otherwise specified). You just met Tony, and you have no way of knowing which diagnoses are the most accurate, which do or do not still apply, or whether later diagnoses "override" earlier diagnoses. So you check them all.
   

• Note that "history of" or "status post" usually means that it is no longer applicable. Examples:
  
   "History of apparent psychotic disorder 25 years ago, none since"
  
   "History of paranoid schizophrenia, current diagnoses residual schizophrenia, alcoholism, and dementia"
  
   "History of cocaine dependence 17 years ago, no use since"

[Back to Top]

Summary of MH/AODA Diagnoses

Check a Diagnosis on the MH/AODA Diagnosis Table When:

• The diagnosis was made by a psychiatrist or licensed psychologist (for psychiatric diagnoses).
• You have the precise DSM-IV numeric code listed, or within a range listed, in the table.
• As far as you can tell (based on your professional expertise and/or lack of contrary evidence) the diagnosis still seems applicable.

Do NOT Check a Diagnosis on the MH/AODA Diagnosis Table When:

• You have the diagnosis but not the DSM-IV numeric code (You could contact the diagnostician to request the diagnosis code).
•  The diagnosis is a psychiatric or AODA diagnoses (even with DSM-IV numeric codes) that is not specified on this table.
• It is another mental, emotional, or behavioral diagnoses not specified on this table.
• It is an older MH/AODA diagnosis that no longer applies (especially if listed only as "history of" and not listed in current diagnoses as well).
• It was not made by a psychiatrist or licensed psychologist (for MI diagnoses).

If after review of medical records and contact with health care providers it is determined that a consumer has no diagnosis, the screener should choose the "No Diagnoses" box.

If an applicant refuses to see a health care professional and does not have any medical records that confirm a diagnosis, enter this information in the "Notes" field on the functional screen.

• Example: "Mr. Smith has not been to the doctor in over four years and refuses to be seen by a health care provider."

You will continue to carry out your normal professional responsibilities to help Mr. Smith get whatever assistance he needs. If he is in immediate danger, you might seek emergency detention for him. If not, you may continue to visit him and establish a relationship with him, such that eventually you can coax him into being seen by a psychiatrist or psychologist. You can then re-do a MH/AODA FS for him, and he might then be eligible for MH/AODA programs. This process is not unlike what counties have always done in Wisconsin.

[Back to Top]

7.3 Global Assessment of Functioning (GAF)

The Global Assessment of Functioning is for reporting the clinicians judgment of the consumer's overall level of functioning. The GAF scale is to be rated with respect only to psychological, social, and occupational functioning. Do not include impairment in functioning due to physical or environmental limitations. In most instances, ratings on the GAF scale should be for the current period (i.e. the level of functioning at the time of the evaluation) because ratings of current functioning will generally reflect the need for treatment or care. If you are obtaining this information from a previous evaluation, please note the date of that evaluation in the Notes Section on the MH/AODA Diagnosis page of the screen.

The GAF does not have to be provided by a psychologist or psychiatrist because this does not affect eligibility for MH or AODA programs. This information should be provided by a qualified clinician who is familiar with using this measure, for example a Licensed Social Worker or a Licensed Professional Counselor.

[Back to Top]

7.4 "Other Diagnoses" Table

The "Other Diagnoses" table does not affect eligibility for MH or AODA programs. It is here to improve, at all levels from practitioners' awareness to county and state systems, the health and access to quality health care for people with mental illness and/or substance use problems. Research shows that the most effective services fully integrate healthcare with mental health and AODA treatment. Functional screen data will help counties and the state move toward more integrated and effective services for all.

Unlike the "Mental Health and AODA Diagnoses" table, the "Other Diagnoses" table is not meant to be all-inclusive; only some of the more common diagnoses are here. For convenience, the diagnoses are grouped by major categories (e.g., Pulmonary, Cardiovascular, Neurological).

If the applicant has no "other" diagnoses, check the "No Diagnoses" box.

Check all that apply, meaning all that are still applicable to the individual. Screeners are not expected to make clinical decisions about whether or not a previous condition still affects an applicant. When you are not sure, go ahead and check the diagnosis in the table. Still, some diagnoses are clearly only in the past and no longer applicable. A few examples include:

• Diagnoses preceded with "history of" or "status post" that are not also listed as current diagnoses.
• A fracture, burn, or wound months or years ago that is now fully healed with no residual impairments.
• A condition that was corrected by surgery or treatment, with no residual impairments.

Again, when in doubt, check the diagnosis on the "Other Diagnoses" table.

Screeners should NOT interpret the applicant's complaints or symptoms. Instead, only check if you have a "verified diagnosis."

• Example: 62-year-old Betty has diabetes and is complaining of increasingly poor vision. You only see a diagnosis of diabetes. You do NOT check "Cataracts/Glaucoma/Diabetic Retinopathy" based on Betty's complaints, because it hasn't been diagnosed yet.

Medical information on a physical diagnosis only is "verified" if it is:

• Stated to screener by an MD, RN, or other health care professional, or
• Copied from recent health care records, or very clearly stated -in exact words--by the person, family, advocate, etc.

There are different requirements for a MH/AODA diagnosis, refer to the previous set of instructions for the complete description of a verifiable MH/AODA diagnosis.

[Back to Top]