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Industry Changes: ICD‐10‐CM and DSM‐5
Surviving Transitions for the Mental Healthcare Professional
Rebecca Lynn Hanif, CPC,CPCO,CCS, CMUA| AHIMA Approved ICD10-CM/PCS Trainer
Agenda
• DSM-5 and ICD-10 Differences
• Coding Psychiatric Diagnoses
• Industry Changes Linked to Accurate Coding
Jackson Thornton
200 Commerce Street
Montgomery, Alabama 36104
334.834.7660
www.jacksonthornton.com
DSM 5 AND ICD‐10 DIFFERENCES
History of ICD-10-CM Classification
• World Health Organization (WHO) adopted in 1990
• United States is the only nation that has not
implemented ICD-10 for the coding of morbidity in a
healthcare facility
• The application of ICD-10-CM will allow the United States
to maintain data comparability internationally and
between mortality and morbidity data within the country
• Implementation kickoff – October 1, 2015
ICD & DSM Background
• Every country is permitted to alter the ICD to fit its
specific needs. In the US, the Center for
Disease Control is charged with that task
• DSM produced by the American Psychiatric
Association
• ICD-10 has more codes and does not align
perfectly with DSM-5
– The name of the disorder in DSM may not be the same as
the name in ICD-10
– I10 crosswalk in DSM might be a different disease
altogether
Diagnosis Code Order
•
The multi-axis system (I-V) introduced with DSM-III has been
eliminated. Coding would regularly use the first three axes for
diagnoses:
– Axis I: Mental and clinical disorders
– Axis II: Personality and clinical disorders
– Axis III: Physical problems that may be relevant to the diagnosis and
treatment of mental disorders
•
•
•
DSM-5 combines all three axes into a single list
ICD-10 uses Z codes for Psychosocial and Environmental
Problems 
GAF  WHODAS
One Code in DSM, Two in I10
• The ICD-10 Agoraphobia diagnosis demands that all
of the following criteria should be fulfilled:
– (a)the psychological or autonomic symptoms must be
primarily manifestations of anxiety and not secondary
symptoms
– (b)the anxiety must be restricted to (or occur mainly in) at
least two of the following situations: crowds, public places,
travelling away from home, and travelling alone; and
– (c)avoidance of the phobic situation must be, or have been,
a prominent feature
• ICD still differentiates Agoraphobia With Panic (F41.0)
and Without Panic(F40.0)--But DSM-5 maps to F41.0.
Fewer Codes in I-10 for Some Disorders
• ICD-10 has the following variants of schizophrenia:
–
–
–
–
–
–
–
–
–
F20.0 Paranoid schizophrenia
F20.1 Hebephrenic schizophrenia
F20.2 Catatonic schizophrenia
F20.3 Undifferentiated schizophrenia
F20.4 Post-schizophrenic depression
F20.5 Residual schizophrenia
F20.6 Simple schizophrenia
F20.8 Other schizophrenia - DSM-5 Schizophreniform
F20.9 Schizophrenia, unspecified - DSM-5 Schizophrenia
Some things Never Change
• PMDD currently maps to the normal physiological
condition of ICD-10 premenstrual tension syndrome
(N94.3)
– N00 – N99 Diseases of the Genitourinary System
– Not a depressive disorder in ICD-10
• It was the same in ICD-9 (625.4)
Differences in Criteria
*WHO version of ICD-10 NOT ICD-10-CM
• DSM-5 PTSD arises from a direct experience,
witnessing it happen to another, hearing about it
happening to a close family member or friend, or
first-responder trauma
• ICD-10-CM does not include diagnostic criteria
• ICD-10 PTSD arises as a response to a stressful event
or situation (either short or long-lasting) of an
exceptionally threatening or catastrophic nature,
which is likely to cause pervasive distress in almost
anyone:
– natural or man-made disaster, combat, serious accident,
witnessing the violent death of others, or being the victim of
torture, terrorism, rape or other crime)
Different Terminology/Different Disease
• Binge-Eating Disorder maps to Other Eating Disorder
(F50.8)
• Hoarding Disorder maps to OCD (F42)
• The NAME and the CODE number should be
recorded in the medical record to support BOTH
DSM and ICD-10
• When mapping “binge-eating” documentation to
ICD-10-CM, another code (F50.02 – Anorexia
Nervosa, binge-eating/purging type) appears as a
choice in some Encoders
Abuse, Use, or Dependence?
• Unique codes for alcohol and drug use, abuse, and
dependence
• Continuous or episodic no longer classified
• History of drug or alcohol dependence coded as “in
remission”
• Combination codes
• F15.20 Dependence (on) (syndrome), amphetamine(s)
(type), see Dependence, drug, stimulant, NEC
• ICD-10-CM classifies each drug by its type. If intoxication
with the dependence is documented, an additional
digit would be added
• DSM-5 Abuse and Dependence categories are no
longer separated
ICD‐10‐CM STRUCTURE AND GUIDELINES FOR PSYCHIATRIC DIAGNOSES
21 Chapters in ICD-10-CM
1. Certain infectious and parasitic dieseases (A00-B99)
2. Neoplasms (C00-D49)
3. Diseases of the blood and blood-forming organs and certain disorders involving the immune
mechanism (D50-D89)
4. Endocrine, nutritional and metabolic disorders (E00-E89)
5. Mental, behavioral and neurodevelopmental disorders (F01-F99)
6. Diseases of the nervous system (G00-G99)
7. Diseases of the eye and adnexa (H00-H59)
8. Diseases of the ear and mastoid process (H60-H95)
9. Diseases of the circulatory system (I00-I99)
10.Diseases of the respiratory system (J00-J99)
11.Diseases of the digestive system (K00-K95)
12.Diseases of the skin and subcutaneous tissue (L00-L99)
13.Diseases of the musculoskeletal system and connective tissue (M00-M99)
14.Diseases of the genitourinary system (N00-N99)
15.Pregnancy, childbirth and the puerperium (O00-O9A)
16.Certain conditions originating in the perinatal period (P00-P96)
17.Congenital malformations, deformations and chromosomal abnormalities (Q00-Q99)
18.Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified
(R00-R99)
19.Injury, poisoning and certain other consequences of external causes (S00-T88)
20.External causes of morbidity (V00-Y99)
21.Factors influencing health status and contact with health services (Z00-Z99)
ICD-10-CM Structure
ICD‐9‐CM
ICD‐10‐CM
•Three to five digits
•First digit is numeric or alpha •Second, third, fourth, and fifth digits are numeric
•Always 3 digits at least
•Decimal placed after first three digits
•Alpha characters are not case sensitive
•Three to seven characters
•First character is alpha
•All letters except U
•Character 2 always numeric
•Characters 3 to 7 alpha or numeric
•Decimal placed after first three digits
•Alpha characters are not case sensitive
ICD-9 Mental Illness – A Foot Note
Codes
Descriptions
290‐294 Organic Psychotic Conditions
295‐299 Other Psychoses
300‐316 Neurotic Disorders, Personality Disorders, and Other Nonpsychotic Mental Disorders
317‐319 Intellectual Disabilities
ICD-10 Mental Illness – The Expansion
Codes
Descriptions
F10‐F19 Mental and Behavioral Disorders due to Psychoactive Substance Abuse
F20‐F29 Schizophrenia, Schizotypal, Delusional, and Other Non‐Mood Disorders
F40‐F48 Anxiety, Dissociative, Stress‐Related, Somatoform and Other Nonpsychotic Mental Disorders
F50‐F59 Behavioral Syndrome Associated with Physiological Disturbances and Physical Factors
F60‐F69 Disorders of Adult Personality and Behavior
F70‐F79 Intellectual Disabilities
F80‐F89 Pervasive and Specific Developmental Disorders
Initial, Subsequent, and Sequela
• T431X1A - Poisoning by MAO inhib antidepressants,
accidental, initial
• T431X1D - Poisoning by MAO inhib antidepressants,
accidental, subs
• T431X1S - Poisoning by MAO inhib antidepressants,
accidental, sequela
A initial encounter
D subsequent encounter
S sequela
Poisonings and External Causes
Combination Codes ICD‐10‐CM
•
T36.0X1S - Poisoning by penicillins,
accidental, sequela
Combination Codes ICD‐9‐CM
•
909.0 - Late effect of poisoning due
to drug, medicinal or biological
substance
–
E929.2 - Late effects of accidental
poisoning
Subdivisions of Chapters in ICD-10-CM
•
•
Categories are usually subdivided into four or five character subcategories
When not subdivided – must be valid code
–
–
•
I10 Essential (primary) hypertension
I10 is a valid 3-character code with no further characters required
“Other Specified” Indicator
I08.89 Other specified rheumatic heart diseases
•
If 8 is the 4th character
after the decimal
point, it is used to
indicate “other
specified”
“Unspecified” Indicator – yes, they do exist in ICD-10-CM
I09.9 Rheumatic heart disease, unspecified
If 9 is the 4th character
it is usually an
unspecified condition
Substance Abuse, Use, and
Dependence
• Like ICD-9-CM, history of dependence coded as
remission
• Blood Alcohol Level coded with Y90. - series
• History of drug or alcohol dependence coded as
“in remission”
– Z Code for Personal History of Dependence on Nicotine
– Z87891- Personal history of nicotine dependence
• Type of tobacco is specified in I-10
Substance Abuse, Use, and
Dependence
• Nicotine dependence and complications:
–
–
–
–
Tobacco product
Cigarettes (F17.21-)
Chewing tobacco (F17.22-)
Other tobacco products (F17.29)
•
•
•
•
•
Uncomplicated
In remission
With withdrawal
With other nicotine-induced disorder
With unspecified nicotine-induced disorder
Substance Abuse, Use, and
Dependence - Tobacco
• Exposure to tobacco:
–
–
–
–
–
Z72.0 Tobacco use
Z87.891 – History of tobacco depenedence
Z77.22 – Exposure to environmental tobacco smoke
P96.81 – Exposure to tocacco smoke in the perinatal period
O99.33 – Tobacco use during pregnancy, childbirth, and
the puerperium
• Patient quits smoking after 24 years of smoking half a pack per day.
She has MILD PERSISTENT ASTHMA. She cannot sleep and is agitated
and nervous. She feels the need to smoke all the time and comes in
to request assistance in quitting:
• F17.213 – Nicotine dependence, cigarettes, with withdrawal
• J45.30 Mild persistent asthma, uncomplicated
Substance Abuse, Use, and
Dependence - Alcohol
• Alcohol use, abuse, and dependence have subcategories
–
–
–
–
–
–
–
–
Uncomplicated
With intoxication
With withdrawal
With alcohol-induced psychotic disorder
With alcohol-induced persisting amnestic disorder
With alcohol-induced persisting dementia
With other alcohol-induced disorder
With unspecified alcohol-induced disorder
Substance Abuse, Use, and
Dependence - Mixed
• If both use and abuse are documented, only abuse
is coded
• If abuse and dependence are documented, only
dependence is coded
• If use, abuse, and dependence are documented,
code only dependence
– Patient with uncomplicated alcohol dependence and
cocaine abuse with cocaine abuse anxiety disorder:
• F10.20 Alcohol dependence uncomplicated
• F14.180 Cocaine abuse with cocaine-induced anxiety
disorder
Substance Abuse, Use, and
Dependence - Mixed
• Other subcategories for drugs include:
– With intoxication (uncomplicated, delirium, perceptual
disturbances, unspecified)
– With induced psychotic disorder (delusions, hallucinations,
other)
– With other induced disorder (anxiety, sexual, sleep, other,
and unspecified)
Depression
• Episode
– Single or recurrent
• Severity
– Mild, moderate, or severe
• With or without psychotic features
• Remission status – partial or full
– 24 year old male presents with symptoms of depression.
These include difficulty sleeping, loss of energy, and feeling
sad. The symptoms began after graduation when he was
unable to find a job. The patient scored a 24 on the Beck
Depression Inventory.
– F32.1 Major depressive disorder, single episode, moderate
Bipolar Disorder
• Type 1 or type II
• Current episode – hypomanic, manic, depressed,
mixed
• Mild, moderate, severe
• With or without psychotic features
• Remission – partial or full
– Patient has a 20 year history of bipolar I disorder for which
she is taking citalopram. She stopped her medications
abruptly and was admitted to the hospital after exhibiting
symptoms of severe mania with psychotic symptoms.
– F31.2 – Bipolar disorder, current episode, manic with moodcongruent psychotic symptoms
– Z91.128 – Patient’s intentional underdosing of medication
regimen
Anxiety and Stress Related Disorders
• Social phobia – F40.1
• Specific (isolated) phobias – F40.2
– F40.2- Animal, natural environment, blood, situational, other
specified
Panic disorder – F41.0
Generalized anxiety disorder – F41.1
Obsessive-compulsive disorder – F42
Acute stress reaction – F43.0
Post-traumatic stress disorder – F43.1 (acute,
chronic, or unspecified)
• Adjustment disorders – F43.2
•
•
•
•
•
Eating Disorders
• Anorexia nervosa, restricting type – calorie
restriction – F50.01
• Anorexia nervosa, binge eating/purging type –
weight loss achieved by vomitting, laxatives,
diuretics – F50.02
• Bulimia nervosa – consumes large amounts of food,
purges, fasts, or over-exercises to get rid of calories
– F50.2
• Body dsymorphic disorder – patient is obsessed with
a nonexistent or slight defect in appearance –
F45.22
Pervasive Developmental Disorders
•
•
•
•
•
Autism – F84.0
Asperger’s – F84.5
Childhood disintegrative disorder – F84.3
Rett’s syndrome – F84.2
Pervasive development disorder not otherwise
specified – F84.9
Coding Psychiatric Diagnoses in ICD-10
• F06.32 Mood disorder due to known physiological
condition with major depressive-like episode
• F43.21 Adjustment disorder with depressed mood
– Justifiable documentation: Situational depression, grief
reaction, culture shock with depressed mood
• F53 Puerperal psychosis
– Justifiable documentation: Postpartum/postnatal
depression
• O90.6 Postpartum mood disturbance
– Justifiable documentation: Postpartum
blues/dysphoria/sadness
• There are “Inclusion Terms”beneath ICD-10 codes
listing alternative language
Other Medical Conditions in ICD-10
• Depressive Disorder Due to Another Medical
Condition DSM-5 293.83
• Code the underlying physiological condition first
F54 - Psychological factors affecting
physical conditions
• Important to code the underlying physical disorder
– the associated physical disorder, such as:
asthma (J45.-)
dermatitis (L23-L25)
gastric ulcer (K25.-)
mucous colitis (K58.-)
ulcerative colitis (K51.-)
urticaria (L50.-)
• This is a new diagnosis for DSM-5 formerly included in
“Other Conditions that may be a Focus of Clinical
Attention” in DSM-IV.
Industry Changes Linked to Accurate Coding
Quality vs. Quantity – Value Based
Payment and Physician Quality
Reporting System
Quality vs. Quantity – Value Based
Payment and Physician Quality
Reporting System
• Clinical quality measures
• Individual physician performance on quality
measures
• Overall costs for patients whose care a physician
directed, contributed to or influenced
• Per capita costs for patients with diabetes, coronary
artery disease, chronic obstructive pulmonary
disease and heart failure
Clinical Quality Measures and ICD-10-CM
•
•
•
•
•
Dementia – Tied to diagnosis codes
Depression – Tied to diagnosis codes
Substance Abuse – Tied to diagnosis codes
9 Measures, 3 domains, 1 cross-cutting measure
Only individuals with cardiovascular disease have
more measures being monitored than those with
mental health and substance use disorders
Clinical Quality Measures and ICD-10-CM
• 33 measures related to behavioral health conditions
or persons with serious mental illness or substance
use disorders
NQS Domains
Measures
Behavioral Health Measures
Community/Care Coordination
35
2
Population Health
12
6
Effective Clinical Care
183
22
Efficiency Cost Reduction
15
0
Patient Safety
30
3
Experience and Outcomes
10
0
Co-morbidities, Mental Health, and ICD-10-CM
• Mental illness is associated with increased
occurrence of chronic diseases such as
cardiovascular disease, diabetes, obesity, asthma,
epilepsy and cancer
• Document and code these co-morbidities
• Revenue and Quality of Care is dependent on the
“full picture”.
• Coordination of care with other Physicians is key
Risk Adjustment Factor and Payment
• Reporting all chronic diseases with an ICD-10-CM
code for every Medicare patient, for every visit will
have a positive impact on the “Risk Adjustment
Factor” used to calculate incentives or penalties in
VBP
Risk Adjustment for No Complications or Non‐specific Coding
Risk Adjustment for Specified Coding with Detailed Documentation
311 Depression NOS F329 (RA= 0) 296.04 Bipolar I, Severe, Psych Behav
F302 (RA = .70)
250.00 Diabetes No Complications
E119 (RA=0.162)
250.40 DM w/ Renal Manif
E1129 (RA=.508)
Quality vs Quantity and Mental Health
• Primary Care MDs can spend 5 to 10 minutes on a
patient and see 10 many patients within the hour
• Psychiatrists spend an hour with one patient and
have been greatly undervalued by both Private
and Government Payors
• The VBP Modifier is an incentive/penalty program
without a budget
– This means that the physicians who receive incentive
payments will be receiving the money from physicians who
are penalized
PENALTIES
YEAR
MU
PQRS
ERX
SEQU
VBM
TOTAL
2012
‐1%
‐1%
2013
‐1.5%
‐2%
‐3.5%
2014
‐2.%
‐2%
‐4%
2015
‐1%
‐1.5%
‐2%
‐1%
‐5.5%
2016
‐2%
‐2%
‐2%
‐2%
‐8%
2017
‐3%
‐2%
‐2%
‐2%
‐9%
2018
Up to ‐
5%
‐2%
‐2%
‐2%
‐11%
2019
Up to ‐
5%
‐2%
‐2%
‐2%
‐11%
An Imperfect System
A number of specialists expressed concern that the cost
measures are inappropriate for some specialties, particularly
single specialty practices. Some specialists objected to basing
cost measures on total amounts billed per patient, since the
specialist is held responsible for care and treatment decisions
for which they have little control. In addition, the majority of
specialists do not even treat one of the four chronic
conditions. CMS responds that the use of total per capita cost
measures for the four chronic conditions reinforces one of the
five principles of the value based payment modifier to
encourage shared accountability for beneficiary care. They
agree with the need to refine the measures for specialties and
to add other chronic conditions. In response to a comment
that Part D costs should be included, CMS will continue to
explore the feasibility of including Part D data in the cost
measures.
Conclusion
• Psychiatry has not undergone as many code
changes as other clinical areas
• The challenge will be using DSM and I10 effectively
and accurately while maintaining compliance with
healthcare reform
References
•
•
•
•
•
•
http://www.thenationalcouncil.org/wp-content/uploads/2014/10/14_Updated-PQRS.pdf
American Psychiatric Association ( 2013) . Diagnostic and Statistical Manual of Mental Disorders
DSM- 5, (5th Edition) . Washington, DC. Author.
American Psychiatric Association. ( 2000) . Diagnostic and Statistical
manual of mental disorders (4th ed., text rev.) . Washington, DC: Author.
http://www.acr.org/Quality-Safety/QualityMeasurement/~/~/media/458AE970DADE468FB990C6455C8C0EEB.pdf
http://www.thenationalcouncil.org/wp-content/uploads/2014/10/14_Updated-PQRS.pdf
http://www.who.int/classifications/icd/en/bluebook.pdf