February 2014


Coding and Documenting in the ICD-10 and New DSM-5: Many Complex Concerns

Thursday, February 27, 2014  by Travis Barker

Coding in ICD-10 will represent a significant change in the behavioral healthcare industry. First, clinicians will likely have to use both the DSM and ICD criteria for diagnostic and clinical documentation purposes. Second, as previously mentioned, there are major differences between the DSM-5 and the ICD-10. For example, Asperger’s Disorder has been removed from the DSM-5, and is now in the Autism Spectrum Disorder category. However, Asperger’s Disorder is listed in the ICD-10, along with its respective specific clinical descriptions and diagnostic criteria. The complexity of diagnosing for clinical and treatment purposes, while concurrently diagnosing for claims purposes, will require changes in workflows.

A major difference between the DSM-5 and ICD-10 involves the Substance Use Section. While the DSM-5 eliminates the distinction between chemical abuse and dependence, the ICD-10 retains the categories of use, abuse, and dependence. There are significantly more substance use diagnoses in the ICD-10 than there are in the DSM-5. Because diagnoses in the DSM-5 have numerous possible iterations in the ICD-10, clinicians expecting a one-to-one code match need to be aware this is not the case.

The ICD-10 lists 10 substances for clinical focus in the Substance Use section while the DSM-IV-TR lists 13. While this is helpful in streamlining diagnostic categories, the number of actual diagnoses in each category has jumped exponentially in the ICD-10. For example in the DSM-IV-TR, there are 9 diagnoses involving Cannabis. In the ICD-10 there are now 44 different possible diagnoses involving Cannabis.

Another concern is that a single diagnosis code may represent very different conditions, ultimately necessitating more detailed clinician documentation. An example of this is the ICD-10 code of F31.64, Bipolar I Disorder, Mixed-category. The distinction between a)severe with psychotic features, b) with mood-congruent psychotic symptoms, and c) mood-incongruent symptoms is not reflected in the code number assigned since all three options are coded the same in the ICD-10. Therefore, in this example the distinction must be made in the clinical documentation portion of the medical record. In the Substance Use category, the need for documentation to delineate the diagnosis is further reflected in the DSM-5 code of F16.94, which can represent four separate diagnoses.

Improving clinical documentation requirements will be important for regulatory and auditing purposes. Given the inherent differences in the DSM-5 versus the ICD-10, decisions will need to be made about coding, diagnosing, terminology, and clinical documentation. One recommendation during this transition period is to establish a Clinical Documentation Improvement program for your organization.

Crosswalks

In order to help providers arrive at the correct diagnosis in the ICD-10, “crosswalks” have been developed to help bridge the translation between the DSM and ICD. Crosswalks typically map between the DSM and the ICD-10 codes to enable the clinician to pick the right code for billing purposes. However, simply cross-walking between the DSM-IV-TR or DSM-5 to the corresponding ICD-10 code will not produce an accurate code number. The ICD-10 is more specific and contains many more diagnoses in the behavioral health section than the DSM-5 contains. This is referred to as the “one-to-many” diagnosis concept of the ICD-10.

It is recommended that you do not attempt to crosswalk every single diagnosis in the DSM to the ICD. Rather, take your most frequently used codes and build your own crosswalk. This will ensure that all of your clinicians use the same desk reference materials to arrive at the right code in the ICD-10.

 

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The ICD-10 Transition: The challenges of Diagnoses and Documentation
Part One

Thursday, February 27, 2014  by Travis Barker

Turtle bites, macaw strikes, and “unspecified event, undetermined intent” are all new and perhaps somewhat bizarre ICD-10 codes that will go into effect on October 1, 2014. While these particular codes may not be ones your healthcare organization is likely to use, the transition will touch every aspect of your business operations and require significant changes to many internal and external processes. Organizations that take the time and invest the resources necessary to understand and properly plan for the transition will be less likely to experience billing disruptions come October 1.

There are two major areas of concern during this transition: clinical diagnosing and documentation. Clinicians will have to learn at least two new, but similar, code sets: the DSM-5 and the ICD-10, with new documentation requirements as a result. Another area of concern involves the entire revenue cycle process. Being dependent on third-party payers and their readiness to accept, process, and reimburse appropriately for healthcare claims received after October 1, 2014 has the potential for significant revenue disruption.

Understanding the Clinical Implications of ICD-10

The Diagnostic and Statistical Manual of Mental Disorders (DSM) has been the mental health and substance use industry’s go-to diagnostic manual for mental illness diagnosis and research for decades. It is what most clinicians are trained to use for clinical diagnostic purposes. Similarly, the International Classification of Diseases (ICD) has been the medical industry’s standard for assigning, diagnosing, and tracking medical conditions worldwide. The ICD is currently in its tenth version, ICD-10, and is published by the World Health Organization (WHO).

The ICD-10 contains approximately 68,000 additional diagnoses and codes compared to its predecessor. Because of the great expansion of medical knowledge in the last 20 years, the ICD-10 list of diagnoses, conditions, causes, and treatments is now expanded to 3-7 digits, up from the previous 3-5 digits in the ICD-9.

How the ICD and DSM Intersect

Behavioral health and substance use provider organizations have historically diagnosed and documented according to DSM criteria, the DSM-IV-TR most recently. When a clinician provides an assessment to a consumer, a DSM-IV-TR diagnosis code is assigned for both clinical documentation and billing. This DSM-IV-TR code is sent to the billing office, which in turn submits an ICD-9 code to a third-party payer for reimbursement. HIPAA requires that only ICD codes be used for reimbursement purposes. Clinicians are not necessarily aware that the DSM-IV-TR code they submit to the billing office is aligned with or “interchangeable” with an ICD-9 code. The numerical similarities between the DSM-IV-TR and ICD-9 codes and the digit-configuration are nearly identical for the Mental and Behavioral Health Codes, which means clinicians do not have to translate a DSM-IV-TR code into an ICD-9 code for billing reasons.

That will change when the United States healthcare industry transitions to ICD-10 codes on October 1, 2014. Organizations will be asked to identify the appropriate ICD-10 code for billing and reimbursement, and will be faced with an additional challenge: policy and procedure decisions regarding the utilization of the DSM-5 for clinical documentation purposes and new documentation standards to support ICD-10 diagnoses. The DSM-5 was released in May, 2013 and the DSM-IV-TR will eventually be retired. The good news is that the newly revised DSM-5 attempts to keep the same coding and structure format as the ICD-10. Because the ICD-10 contains many more codes than the DSM-5, clinicians may have to use two different manuals, desk references, and/or mappings to record a clinical service. Additionally, because of the increased specificity of the ICD-10 codes, there will also be cases in which a single DSM-5 code does not exactly align with a corresponding ICD-10 code. As a result, clinicians will be faced with having to know both code sets in order to clinically document, and subsequently bill, third-party payers.

Conflicting information and timelines about the utilization of the DSM-5 exist in the field. For example, many payers still require DSM coding for clinical documentation of prior authorizations, pre-certifications, and treatment reviews. Different payers will require the change from the DSM-IV-TR to DSM-5 at different times. Finally, there are some organizations, both providers and payers, that will choose to use the ICD-10 only and not use the DSM at all.

The end result is organizations will need to know the different code sets, which payer requires what type of diagnostic coding criteria, as well as the ICD-10 codes for claims and revenue cycle purposes. The payers who require the DSM-5 will vary, as will their respective implementation timelines. It will be crucial for organizations to know these requirements and timelines to minimize potential negative impact to revenue.

Next: Coding and Documenting in the ICD-10 and New DSM-5: Many Complex Concerns

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