ICD-10 and DSM-5 for Behavioral Health

In the mental health field, many psychiatric clinicians use the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), and, since May 19, 2013, the updated DSM-5 for diagnosing mental disorders.   Psychiatric specialists have knowledge and a comfort level with the DSM for clinical decision-making. When planning for ICD-10, it is important to understand CMS policy about the intended purpose of ICD-10 and the DSM.  As Benjamin F. Miller, PsyD and Assistant Professor from the University of Colorado School of Medicine notes, the DSM-IV addressed diagnostic codes only for the purpose of describing mental disorders; but ICD-10-CM provides for both physical and mental disorders.

“It is important to note that there are other differences between the DSM-V and ICD-10. For example, the DSM was produced by a single national professional association for psychiatrists (the American Psychiatric Association) while the ICD was produced by a global health agency with a public health mission to help countries reduce the disease burden including mental disorders; the DSM generates revenue for the American Psychiatric Association while the ICD is free through the internet; the DSM  was developed primarily by psychiatrists with the ICD’s development being multidisciplinary; and, the  DSM as a manual is approved by the American Psychiatric Association while the ICD is approved by the World Health Assembly.”  See http://www.ncvhs.hhs.gov/wp-content/uploads/2014/05/130618p15a.pdf sourced February 22, 2014.

It is not surprising that I have noted some conflicting information on the American Psychological Association (APA) bulletins on the use of the DSM and ICD-10.  Going forward, CMS has made a clear statement about the intended use of ICD-10 with respect to reimbursement for Behavioral health providers.

According to CMS, “…neither the DSM-IV nor the DSM-5 is a HIPAA Compliant code set. Therefore, Behavioral Health specialists must use ICD-9 CM codes and after October 1, 2015 the appropriate ICD-10 CM diagnosis code.”

Additionally, for inpatient procedures, ICD-10 PCS must also be used, and for ambulatory procedures, ICD-10 CM diagnosis must be paired with CPT codes.

Do Fewer Codes for Behavioral Health Mean Less Complexity and an “out” from doing a proper ICD-10 Assessment?  No. Here’s Why.

There are relatively few increases in ICD-10 codes in behavioral health relative to high impact specialties such as Orthopedics.  For example, there are 27 ICD-9 codes for Anxiety Disorders and 47 codes under ICD-10.  Schizophrenia codes are reduced from 56 in ICD-9 to 11 in ICD-10.  Therefore, some behavioral health providers assume in error that because there are fewer codes that the ICD-10 transition has little impact on their organization, which is not true.  Because DSM is used for clinicians and ICD-10 for reimbursement, there is an increased level of complexity.   Local and state requirements regarding the use of DSM and ICD-10 vary, which then causes you to consider:

Can you eliminate DSM if not required in your state?

Should you map or crosswalk from DSM-IV to DSM-5 to ICD-10?  If this is your strategy you may consider:

  • This approach will require an understanding of changes in medical concepts between the DSV-IV and DSM-5, and whether you have DSM or ICD codes dependencies in your systems.
  • Education opportunities including helping behavioral health organizations appreciate the nuances of various reimbursement acronyms and standards that are inter-related. For example, a Behavioral specialty provider recently stated, “…we don’t use DRGs we use Inpatient Psychiatric Facility Prospective Payment System (IPF PPS).” In fact the facility is using DRGs. According to CMS

…IPF PPS, Federal per diem rates include inpatient operating and capital-related costs (including routine and ancillary services) and are determined based on:

  • Geographic factors:
    • A hospital wage index value is assigned to account for geographic differences in wage
    • The non-labor-related portion accounts for higher cost of living for IPFs located in Alaska and Hawaii;
  • Patient characteristics:
    • Medicare Severity-Diagnosis Related Group (MS-DRG) classification;
    • Age;
    • Presence of specified comorbidities; and
    • Length of stay; and
  • Facility characteristics:
    • A 17 percent payment adjustment for rural facilities due to their higher costs; and
    • Teaching hospitals receive payment to account for indirect medical education costs…

How to Successfully Transition Behavioral Health Organizations to ICD-10

  • Ensure that you hire or retain consulting expertise knowledgeable in both DSM-5 and ICD-10, and the purpose and usage of these codes throughout the mental health specialty organization and physician group.
  • Include psychiatric clinicians with knowledge of the DSM on your team.
  • Ensure proper knowledge transfer to your coding, billing, clinical and operations staff.
  • Consider patient referral documentation and its impact on your reimbursement, and ensure that non-employed physicians as a source of referral are engaged as much as possible.
  • Identify those departments that are using DSM codes.
  • Determine if the codes being used are DSM-4 or DSM-5.
  • Evaluate patient intake systems, reporting, and more for DSM-4 or ICD-9 specific dependencies
  • Consider payor contracting factors.  Even if your payor contracts are per-diem or if you have self-pay clients, you must consider the reporting and potential audit risk if you do not use the HIPAA required ICD-10 codes.

Additional Factors – Affordable Care Act Quality Measures for Behavioral Health and ICD-10

Section 1886(s)(4)(C) of the Social Security Act, amended by sections 3401(f) and 10322(a) of the Affordable Care Act requires IPFs to report quality data for 6 quality measures starting in fiscal 2013 for Medicare beneficiaries.   Beginning in FY 2015, two quality measures are added.   Failure to comply with these regulations will result in a 2 percent reduction to the applicable base rate for IPFs.  (Source: Medicare Learning Network publication Inpatient Psychiatric Facility Prospective Payment System).  Why does this matter in the context of ICD-10?   The quality measures will be based on diagnosis and procedures coded in ICD-10 beginning October 1, 2015.

How to establish whether DSM and ICD-10 requirements impact your IT systems and processes

  • Consider the specificity of clinical documentation that your HIM systems support.   If you use an Electronic Medical Record, determine whether it supports not only the proper level of specificity in the DSM (if it is required by your State or local laws) but also the specificity to support ICD-10.
  • Determine what impact these changes have on your revenue cycle management systems and processes.
  • In a recent engagement with a regional freestanding Behavioral health provider, we determined that at least forty (40) processes related to RCM are impacted.
  • Ensure that your systems support both the entry, storage, and reporting of both ICD-10 and the IPF quality measure reporting as above.  Otherwise even Federal per diem rate facilities who might otherwise believe that ICD-10 has no impact may risk substantial reductions in their Medicare reimbursement, as well as other possible regulatory consequences.
  • Determine whether your analytic systems also need to be re-tooled based on ICD-10 and the resulting quality reporting requirements mentioned above.
  • Develop a test plan that comprehends all of these issues. Without testing the entire end-to-end process from patient chart to coding, billing, claim submission and reimbursement, your assumption that you will be ready on October 1, 2014 without a reimbursement or compliance risk will only be theoretical.
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Michael F. Arrigo

Michael Arrigo brings four decades of experience in the software, financial services, and healthcare industries. In 2000, Mr. Arrigo founded No World Borders, a healthcare data, regulations, and economics firm with clients in the pharmaceutical, medical device, hospital, surgical center, physician group, diagnostic imaging, genetic testing, health IT, and health insurance markets. His expertise spans the federal health programs Medicare and Medicaid and private insurance. He advises Medicare Advantage Organizations who provide health insurance under Part C of the Medicare Act. Mr. Arrigo serves as an expert witness regarding medical coding and medical billing, fraud damages, as well as electronic health record software for the U.S. Department of Justice. He has valued well over $1 billion in medical billings in personal injury liens, medical malpractice, insurance fraud cases. The U.S. Court of Appeals considered Mr. Arrigo's opinion regarding loss amounts, vacating, and remanding sentencing in a fraud case. Mr. Arrigo provides expertise in the Medicare Secondary Payer Act, Medicare LCDs, anti-trust litigation, medical intellectual property and trade secrets, HIPAA privacy, health care electronic claim data Standards, physician compensation, Anti-Kickback Statute, Stark law, the Affordable Care Act, False Claims Act, and the ARRA HITECH Act. Arrigo advises investors on merger and acquisition (M&A) diligence in the healthcare industry on transactions cumulatively valued at over $1 billion. Mr. Arrigo spent over ten years in Silicon Valley software firms in roles from Product Manager to CEO. He was product manager for a leading-edge database technology joint venture that became commercialized as Microsoft SQL Server, Vice President of Marketing for a software company when it grew from under $2 million in revenue to a $50 million acquisition by a company now merged into Cincom Systems, hired by private equity investors to serve as Vice President of Marketing for a secure email software company until its acquisition and multi $million investor exit by a company now merged into Axway Software SA (Euronext: AXW.PA), and CEO of one of the first cloud-based billing software companies, licensing its technology to Citrix Systems (NASDAQ: CTXS). Later, before entering the healthcare industry, he joined Fortune 500 company Fidelity National Financial (NYSE: FNF) as a Vice President, overseeing eCommerce solutions for the mortgage banking industry. While serving as a Vice President at Fortune 500 company First American Financial (NYSE: FAF), he oversaw eCommerce and regulatory compliance technology initiatives for top ten mortgage banks and led the Sarbanes Oxley Act Section 302 internal controls IT audit for the company, supporting Section 404 of the Sarbanes Oxley Act. Mr. Arrigo earned his Bachelor of Science in Business Administration from the University of Southern California. Before that, he studied computer science, statistics, and economics at the University of California, Irvine. His post-graduate studies include biomedical ethics at Harvard Medical School, biomedical informatics at Stanford Medical School, blockchain and crypto economics at the Massachusetts Institute of Technology, and training as a Certified Professional Medical Auditor (CPMA). Mr. Arrigo is qualified to serve as a director due to his experience in healthcare data, regulations, and economics, his leadership roles in software and financial services public companies, and his healthcare M&A diligence and public company regulatory experience. Mr. Arrigo is quoted in The Wall Street Journal, Fortune Magazine, Kaiser Health News, Consumer Affairs, National Public Radio (NPR), NBC News Houston, USA Today / Milwaukee Journal Sentinel, Medical Economics, Capitol ForumThe Daily Beast, the Lund Report, Inside Higher Ed, New England Psychologist, and other press and media outlets. He authored a peer-reviewed article regarding clinical documentation quality to support accurate medical coding, billing, and good patient care, published by Healthcare Financial Management Association (HFMA) and is published in Healthcare IT News.

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