In the realm of insurance claims, particularly those involving emotional harm, a thorough and accurate diagnosis is paramount. Leveraging the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), published by the American Psychiatric Association, is crucial for claim professionals navigating these complex cases. This guide delves into how understanding mental illness diagnoses, specifically the often overlooked “799.9 Diagnosis Code,” can be instrumental in identifying critical issues and ensuring equitable claim resolutions.
The Cornerstone of Equitable Claims: Obtaining a Diagnosis
The initial, and often most vital step in analyzing emotional harm claims is securing a definitive diagnosis. Regrettably, a significant number of medical evaluations fail to provide a clear diagnosis, even after extensive claimant examinations. Therefore, proactively requesting and insisting upon a diagnosis becomes a key element in the claim analysis process. Since 1980, the DSM has advocated for, though not mandated, mental health professionals to employ a multiaxial system for diagnosing mental disorders. This multiaxial assessment framework is designed to facilitate a comprehensive and systematic evaluation, capturing the intricate nature of clinical scenarios and acknowledging the diverse presentations of individuals sharing the same diagnosis.
Unveiling the Complete Picture: The DSM Multiaxial System
The DSM multiaxial system has long been a recognized and respected standard within the mental health community. A comprehensive forensic mental health evaluation, essential for insurance claim assessments, should ideally present diagnostic formulations across all five Axes (I through V). Even in situations where an opinion on a specific axis is deferred due to insufficient information, this should be explicitly stated and justified.
However, in the context of insurance claims, it is alarmingly common to encounter reports that only provide diagnoses on Axis I. This omission of diagnoses across all five axes serves as a significant indicator to the claims examiner that the claimant may not have undergone a complete and thorough evaluation, potentially lacking a comprehensive differential diagnosis. This is where understanding the implications of codes like “799.9 diagnosis code,” especially when associated with Axis II, becomes critical.
Understanding the DSM-IV-TR Multiaxial Diagnostic System
To effectively utilize diagnostic information, particularly in identifying potential shortcomings in evaluations, it’s essential to understand the structure of the DSM-IV-TR multiaxial system:
Axis I: Clinical Disorders
This axis encompasses over 200 distinct mental disorders, categorized into broader groups. Examples of these groupings include: Delirium, Dementia, and Amnestic and Other Cognitive Disorders; Mental Disorders Due to a General Medical Condition; Substance-Related Disorders; Schizophrenia and Other Psychotic Disorders; Mood Disorders; Anxiety Disorders; and Somatoform Disorders. It’s important to note that claimants may present with multiple co-occurring disorders, leading to the possibility of multiple Axis I diagnoses.
A common pitfall observed in medical evaluations is the tendency for some practitioners to diagnose a mental disorder for virtually every symptom reported by the claimant. This can result in an excessive number of overlapping and often redundant Axis I diagnoses. Such instances can often be identified by observing that the claimant’s reported level of daily functioning appears inconsistent with the presence of multiple major mental disorders.
Another diagnostic error arises when clinicians assign a diagnosis merely based on symptom similarity to the disorder’s name. For instance, an adult exhibiting a short attention span might be incorrectly diagnosed with Attention-Deficit/Hyperactivity Disorder (A-D/HD), despite the established diagnostic criteria requiring symptom onset before the age of 7. Similarly, Post Traumatic Stress Disorder (PTSD) is frequently misdiagnosed when a claimant displays normal distress following a traumatic event, without a rigorous assessment against the 6 diagnostic criteria and 21 symptoms specifically outlined for PTSD.
Furthermore, clinicians sometimes overlook substance-related disorders on Axis I, particularly concerning commonly used substances such as nicotine and alcohol. This oversight can be a valuable indicator that the clinician has not adequately considered the potential impact of substance abuse or dependence on the claimant’s overall mental health. Frequently missed mental disorders in this category include Alcohol-Induced Mood, Anxiety, and Sleep Disorders.
Axis II: Personality Disorders and Mental Retardation
Axis II focuses on personality disorders and mental retardation. A personality disorder is defined as an enduring and inflexible pattern of inner experience and behavior that deviates significantly from cultural expectations, is pervasive across various situations, has its onset in adolescence or early adulthood, remains stable over time, and causes significant distress or impairment in functioning. The DSM-IV-TR identifies 10 distinct pathological personality types. Critically, none of these personality disorders originate in adulthood, nor can they be directly caused by commonly insured events like motor vehicle accidents or slip and fall injuries.
Claimants frequently present with pre-existing Axis II personality disorders that significantly influence their behavior and can complicate or even impede efforts to reach a fair settlement. Despite this prevalence, psychological and psychiatric experts evaluating claimants often neglect to thoroughly assess for personality disorders. Comprehensive personality disorder assessment is a time-consuming process that can potentially strain the doctor-patient relationship, which may contribute to this oversight.
This common oversight is often signaled by a diagnosis of “799.9 Diagnosis Deferred on Axis II” or even the complete absence of any mention of Axis II in the evaluation report. The 799.9 diagnosis code itself, under the ICD-9 system (the coding system relevant to DSM-IV-TR), signifies an unspecified or deferred diagnosis. In the context of Axis II, a 799.9 code strongly suggests that a personality disorder assessment was either not conducted or was inconclusive, leaving a critical aspect of the claimant’s mental health profile unexamined.
When deposing a mental health expert, it is crucial to directly inquire about the methods employed to systematically rule out the presence of a personality disorder. While a detailed discussion of personality assessment methodologies is beyond the scope of this article, common assessment tools typically include the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) or structured interviews such as the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-2).
Axis III: General Medical Conditions
Axis III is designated for documenting all past and present physical conditions, injuries, and diseases that could potentially impact the claimant’s psychological state. Conditions such as anemia, diabetes, hypertension, hypothyroidism, lupus, and Lyme disease are examples of general medical conditions frequently associated with psychiatric symptoms.
It is rarely the case that the insured event is the direct cause of these general medical conditions. If the claimant’s medical expert has not listed a claimant’s pre-existing general medical condition on Axis III, it is reasonable to assume that these conditions have not been adequately considered as potential non-proximal causes of the claimant’s reported emotional symptoms.
Axis IV: Psychosocial and Environmental Problems
Axis IV serves to record all past and current psychosocial stressors that may influence the diagnosis, treatment, and prognosis of mental disorders identified on Axes I and II. Psychosocial stressors often play a significant role in the onset, severity, exacerbation, and maintenance of mental illnesses.
Insurers should compare their knowledge of the claimant’s psychosocial stressors with those documented by the claimant’s medical expert. This comparison ensures that neither party underestimates the potential impact of these problems on the claimant’s presentation. Unrelated stressors such as marital difficulties, child behavior problems, or the presence of chronically ill parents commonly produce psychological symptoms that are mistakenly attributed solely to the insured event.
Axis V: Global Assessment of Functioning (GAF)
Axis V employs a 100-point scale to rate the patient’s overall level of psychological, social, and occupational functioning. Crucially, when applied according to DSM guidelines, the GAF scale is intended to exclude impairments stemming from physical or environmental limitations.
In insurance claims, clinicians often provide inappropriately low GAF ratings by erroneously incorporating impairments due to physical or environmental limitations. This error is sometimes explicitly noted in the record (e.g., “GAF=30 due to inability to walk or drive a car”). Identifying such errors allows for a more accurate interpretation of severity ratings, bringing them in line with the actual level of emotional harm experienced.
Chronic vs. Recurrent: Clues to Causality
The DSM system incorporates specifiers that can be applied to many diagnoses commonly encountered in insurance claims. “Chronic” and “recurrent” are two specifiers of particular relevance. In the context of a Major Depressive Episode, the specifier “chronic” indicates that the full diagnostic criteria for a Major Depressive Episode have been continuously met for at least the preceding two years. This often places the onset of the condition prior to the insured event, supporting the possibility that a pre-existing mental disorder is being inaccurately attributed to the insured event as a proximal cause.
The specifier “recurrent” signifies that the claimant’s condition follows a pattern of periods of symptom exacerbation and remission, with partial to complete recovery between episodes. When substantiated by medical records and deposition testimony, this specifier can demonstrate that the insured event was merely a coincidental occurrence within a long-standing and ongoing pattern of recurrent mental illness. In numerous cases, this pre-existing pattern of recurrent illness was neither caused nor exacerbated by the claimant’s involvement in the insured event.
Distinguishing Course from Severity
It is crucial to understand that neither “chronic” nor “recurrent” specifiers relate to the severity of the claimant’s symptoms. Instead, the DSM provides terms like “mild,” “moderate,” and “severe” to specifically denote symptom severity. For instance, a claimant may have a “chronic” condition of “mild” severity, or experience “recurrent” episodes of “severe” depression interspersed with months or years of complete recovery.
Medical experts frequently fail to make these critical distinctions. They may incorrectly diagnose a “recurrent” disorder when they actually intend to describe a severe and chronic condition. Clarifying the clinician’s intended use of specifiers for both the course and severity of the claimant’s alleged mental disorder is therefore an essential objective during deposition.
Severity Specifiers and Damage Assessment
In insurance claims, inconsistencies often arise between the severity specifier used in the narrative diagnosis, the numerical code billed for treatment, and the signs and symptoms documented in the medical records. Insurers should verify that the descriptive label aligns with the numerical code utilized in medical records and billing statements. Discrepancies in these areas can seriously undermine the validity of the expert’s medical opinion or suggest that the claimant’s treatment is not appropriately targeted towards the correct disorder. Paying close attention to diagnostic coding, including instances of “799.9 diagnosis code,” and understanding the context within the DSM-IV-TR framework is vital for accurate and equitable claim resolution.
