Module 6: Diagnoses

6.1 Introduction

There are two diagnoses tables on the screen. The first is for mental illness and substance use related diagnoses. The second is to indicate other general medical diagnoses. Psychiatric diagnoses are needed for eligibility for mental health and substance use programs. Other or general medical diagnoses do not affect eligibility for mental health and substance use programs. The other diagnoses are included on the screen to improve the well-being and access to quality health care for people with mental illness and/or substance use needs.

6.2 Mental health and substance use diagnoses

The screen reflects current federal and state policies on eligibility for Medicaid-funded mental health and substance use disorder programs.

Specific psychiatric or substance use disorder diagnoses are required for eligibility for most mental health and substance use disorder programs in Wisconsin. Nicotine addiction is listed but does not count toward eligibility for substance use disorder treatment programs.

Psychiatric diagnoses must be made by a psychiatrist, licensed psychologist, physician, licensed clinical social worker, licensed professional counselor, licensed marriage and family counselor, or advanced practice nurse practitioner for whom diagnosing a mental health is appropriate to their specialization and within the scope of their training and practice.

Substance use diagnoses checked in the screen should reflect diagnoses made by professionals whose scope of practice includes diagnosing substance use disorders (psychiatrist, licensed psychologist, physician, licensed clinical social worker, licensed professional counselor, licensed marriage and family counselor, substance use disorder professional, or advanced practice nurse practitioner).

Where screeners obtain diagnoses

Screeners can obtain diagnoses through:

Written records from a psychiatrist or licensed psychologist.
Other medical records if the psychiatric diagnosis was made by a psychiatrist, licensed psychologist, or other professional as allowable by the screen.
A health care or mental health professional’s verbal report that a qualified professional made a particular diagnosis.

Documentation from schools or group homes does not count unless the documentation cites a diagnosis made by a qualified diagnostician. In other words, school category assignments or diagnoses made by teachers or direct care staff do not count.

An applicants or family report count 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 to verify diagnoses.

Sometimes the applicant will need assistance to see a qualified diagnostician to obtain formal diagnoses required for entry into mental health and substance use disorder treatment programs.

If, after review of medical records and contact with health care providers, it is determined that an applicant 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 screen.

Diagnoses not listed

The DSM-5-TR includes some diagnoses that do not count toward eligibility for mental health and substance use disorder programs. Examples include intellectual disability, learning disorder, attention deficit/hyperactivity disorder, and dementia. Contact the agency screen lead if there is belief someone with a diagnosis not on the table should be eligible for mental health and substance use disorder programs.

Multiple diagnoses over time

The same individual may be given different diagnoses by different qualified diagnosticians at different times. Below are some guidelines to follow:

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 has received different diagnoses at different times, there are two choices:
- Check only the most recent diagnoses if earlier diagnoses seem no longer accurate or applicable.
- Check all the diagnoses if you’re not sure which are the most accurate or whether they still apply.

Screeners are not expected to make clinical decisions about whether a diagnosis is accurate or still applicable for an applicant. When not sure, check the diagnosis in the table.

Note that history of or status post usually means that it is no longer applicable.

6.3 Other diagnoses table

The other diagnoses table does not affect eligibility for mental health and substance use disorder programs. It is here to improve the health and access to quality health care for applicants with mental health and substance use diagnosis needs. Research shows that the most effective services fully integrate health care with mental health and substance use treatment.

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 a previous condition still affects an applicant. When not sure, check the diagnosis in the table.

If a major injury, surgery, or illness happened in the past and no longer impairs the individual, then the screener should not note it in this section.

Screeners should not interpret the applicant’s complaints or symptoms. Instead, only check if there is a verified diagnosis.

Medical information on a physical diagnosis is verified if it is one of the following:

Stated to screener by a doctor, nurse, or other health care professional
Copied from recent health care records or very clearly stated in exact words by the applicant, family, advocate, etc.