Mental Health Information System (MHIS) Manual

Page Posted: 06/02/14

Page Reviewed: 8/22/2022

Page Updated: 8/12/2019

5.1.4. Diagnostic Assessment and Substance Use Screening

VARIABLE NAME: Diagnosis Assessment Date

DESCRIPTION: Identifies the most recent date the Diagnostic Assessment was completed. See Guidelines for absence of a Diagnostic Assessment.

VALID ENTRIES: 2- digit month and day followed by the 4-digit year. The numeric format for months and days 1-9 must have a zero as the leading digit.

GUIDELINES:

· See the MHCP Provider Manual Diagnostic Assessment page for additional information on Diagnostic Assessment criteria.

· Use the following guidelines in the absence of a Diagnostic Assessment:

· Crisis grantees and providers - report the Crisis Assessment Date and diagnosis

· Hospitals - report the Psychiatric Assessment date and diagnosis

· Housing with Supportive grantees - report mental health professional date and diagnosis

· If the client was not engaged with traditional mental health services prior to the status record, enter [01/01/1900] as the Diagnostic date, [999.9997] Unknown for the Primary level diagnosis.

· Update the client record once you are able to collect the information from Mental Health Provider, when the individual engages with traditional mental health services or Diagnostic Assessment is completed.

FIELD NUMBER: C32

FIELD LENGTH: 10

FIELD TYPE: DATE

FORMAT: MM/DD/YYYY

VARIABLE NAME: Primary Level Diagnosis

DESCRIPTION: Specifies the client’s current clinical disorders, including major mental disorders, learning disorders and substance use disorders per specified assessment in Diagnosis Assessment Date field.

VALID ENTRIES:

· DSM-5/ICD-10 codes

· Accepted values fall within the billable Mental Health Diagnostic Code Ranges as listed in the MHCP Provider Manual.

[999.9997] Unknown

GUIDELINES:

· Agencies are allowed to report the three most recent and current diagnoses during the reporting period. Most recent is defined by the date when the diagnosis was reported.

· Use code [999.9997] Unknown if the Agency collects this data but for some reason a particular record does not reflect an acceptable value.

· The ICD-10 primary diagnosis will start with F, up to 8 characters

FIELD NUMBER: S1

FIELD LENGTH: 8

FIELD TYPE: Text

FORMAT: XXXXXXXX

VARIABLE NAME: Secondary Level Diagnosis

DESCRIPTION: Specifies the client’s current clinical disorders, including major mental disorders, learning disorders and substance use disorders per specified assessment in Diagnosis Assessment Date field.

VALID ENTRIES:

· DSM-5/ICD-10 codes

· Accepted values fall within the billable Mental Health Diagnostic Code Ranges as listed in the MHCP Provider Manual.

[999.9997] Unknown

[999.9996] No Diagnosis

GUIDELINES:  

· Optional reporting

· Codes entered in Primary Diagnosis field cannot be repeated in Secondary Diagnosis field.

· Use code [999.9996] No Diagnosis if the client has no secondary diagnosis that has been reported.

· Use code [999.9997] Unknown if the Agency collects these data but for some reason a particular record does not reflect an acceptable value.

· The ICD-10 secondary diagnosis will start with F, up to 8 characters

FIELD NUMBER: S2

FIELD LENGTH: 8

FIELD TYPE: Text

FORMAT: XXXXXXXX

VARIABLE NAME: Tertiary Level Diagnosis

DESCRIPTION: Specifies the client’s current clinical disorders, including major mental disorders, learning disorders and substance use disorders per specified assessment in Diagnosis Assessment Date field.

VALID ENTRIES:

· DSM-5/ICD-10 codes

· Accepted values fall within the billable Mental Health Diagnostic Code Ranges as listed in the MHCP Provider Manual.

[999.9997] Unknown

[999.9996] No Diagnosis

GUIDELINES:

· Optional reporting

· Codes entered in Primary Diagnosis and Secondary Diagnosis fields cannot be repeated in Tertiary Diagnosis field.

· Use code [999.9996] No Diagnosis if the client has no secondary diagnosis that has been reported.

· Use code [999.9997] Unknown if the Agency collects these data but for some reason a particular record does not reflect an acceptable value.

· The ICD-10 secondary diagnosis will start with F, up to 8 characters

FIELD NUMBER: S3

FIELD LENGTH: 8

FIELD TYPE: Text

FORMAT: XXXXXXXX

VARIABLE NAME: WHODAS 2.0 Score (12-item version)

DESCRIPTION: Specifies the client’s current WHODAS 12-item version score per specified assessment in Diagnosis Assessment Date field.

VALID ENTRIES:

· WHODAS 12-item version score: 12-60

[996]   Not Required

[997]  Unknown

GUIDELINES:  

· Report on WHODAS 12-item OR WHODAS 32-item

· Report the client’s score at time of reported diagnostic assessment date.

· Use code [996] Not Required where WHODAS is not required.

· Use code [997] Unknown if the Agency collects these data but for some reason a particular record does not reflect an acceptable value.

· Effective July 1, 2018, the World Health Organization Disability Assessment Schedule (WHODAS 2.0) will no longer be a required component for capturing functional status in the diagnostic assessments for adults in Minnesota Health Care Programs (MHCP). To align with the current Diagnostic and Statistical Manual (DSM), federal guidelines, and state regulations for functional impacts, providers must ensure symptom descriptions, at a minimum the frequency, intensity and impact, are integrated into the diagnostic assessment. Include this information in the clinical summary. The WHODAS 2.0 is still an acceptable method to capture functional status in a diagnostic assessment for adults. The functional status components required for children 0-5 years old (ECSII, SDQ) and 5-18 years old (CASII, SDQ) will remain the same. (pub. 5/30/18)

· Use code [996] Not Required when Diagnostic Assessment captures functional status in the clinical summary.

· Report WHODAS score when included in the Diagnostic Assessment

FIELD NUMBER: S4

FIELD LENGTH: 3

FIELD TYPE: Numeric

FORMAT: XXX

VARIABLE NAME: WHODAS 2.0 Score (36-item version)

DESCRIPTION: Specifies the client’s current WHODAS 36-item version score per specified assessment in Diagnosis Assessment Date field.

VALID ENTRIES:

· WHODAS 36-item version score: 36-180

[996] Not Required

[997] Unknown

GUIDELINES:

· Report on WHODAS 12-item OR WHODAS 32-item

· Report the client’s score at time of reported diagnostic assessment date.

· Use code [996] Not Required where WHODAS is not required.

· Use code [997] Unknown if the Agency collects these data but for some reason a particular record does not reflect an acceptable value.

· Effective July 1, 2018, the World Health Organization Disability Assessment Schedule (WHODAS 2.0) will no longer be a required component for capturing functional status in the diagnostic assessments for adults in Minnesota Health Care Programs (MHCP). To align with the current Diagnostic and Statistical Manual (DSM), federal guidelines, and state regulations for functional impacts, providers must ensure symptom descriptions, at a minimum the frequency, intensity and impact, are integrated into the diagnostic assessment. Include this information in the clinical summary. The WHODAS 2.0 is still an acceptable method to capture functional status in a diagnostic assessment for adults. The functional status components required for children 0-5 years old (ECSII, SDQ) and 5-18 years old (CASII, SDQ) will remain the same. (pub. 5/30/18)

· Use code [996] Not Required when Diagnostic Assessment captures functional status in the clinical summary.

· Report WHODAS score when included in the Diagnostic Assessment

FIELD NUMBER: S5

FIELD LENGTH: 3

FIELD TYPE: Numeric

FORMAT: XXX

VARIABLE NAME: Substance Abuse Screening

DESCRIPTION: Outcome of Substance Abuse screening that is completed at the time of the reported assessment in Diagnosis Assessment Date field.

VALID ENTRIES:

[1] Screened: Negative

[2] Screened: Positive

[3] Not Screened

[9] Unknown

GUIDELINES:

· Screening for the likelihood of substance use disorders is required at the time that the assessment is completed. Screening must be done using a screening tool approved by the Commissioner. For more information on approved screening tools see the MHCP Provider Manual Diagnostic Assessment page and the Diagnostic Assessment (DA) Report Components page

FIELD NUMBER: C43

FIELD LENGTH: 1

FIELD TYPE: Text

FORMAT: X