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DSM-5 Administrative and Business Implications

July 31, 2013

National Council for Behavioral Health


202.684.7457

• Clinicians may use DSM-5 in their practices immediately may be brief delays while insurance companies

update their claim forms and reporting procedures clinicians should use DSM-IV-TR diagnoses and codes

when required by a specific company • Transition to DSM-5 by the insurance industry should be

completed by December 31, 2013 • Need to be updates of questions in board

certification examinations and quality assessments for medical record review

Adoption of DSM-5

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• clinicians may continue to base their diagnostic decisions on the DSM-IV/DSM-5 criteria crosswalk those decisions to the appropriate ICD-9-

CM and, as of October 1, 2014, ICD-10 CM codes. • permissible for to use the DSM-IV and DSM-5 codes,

descriptors and diagnostic criteria for other purposes medical records quality assessment medical review consultation patient communications

CMS Perspectives

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• DSM-5 continues to use statistical codes contained in the U.S. Clinical Modifications (CM) of the World Health Organization’s (WHO’s) International Classification of Diseases (ICD)

• The ICD-9-CM contains the internationally approved statistical codes for all medical diseases or disorders does not contain detailed descriptions of how to

diagnose these conditions

Coding of Diagnosis

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• DSM-5 is completely compatible with the HIPAA-approved ICD-9-CM coding system now in use by insurance companies

• revised criteria for mental disorders can be used immediately for diagnosing mental disorders …however, the change in format from a multi-axial

system in DSM-IV-TR may result in a brief delay while insurance companies update their claim forms and reporting procedures to accommodate DSM-5 changes

DSM-5 Compatibility

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• On October 1, 2014, the United States adopts ICD-10-CM as its standard coding system

• DSM-5 contains both ICD-9-CM codes for immediate use and ICD-10-CM codes in parentheses

• The inclusion of ICD-10-CM codes facilitates a cross-walk to the new coding eliminate the need for separate training on ICD-

10-CM codes for mental disorders

ICD-10

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• DSM-5 combines the first three DSM-IV-TR axes into one list that contains all mental disorders, including personality disorders intellectual disability other medical diagnoses

• Single axis recording procedure was previously used for Medicare and Medicaid reporting some insurance companies required clinicians to

report on the status of all five DSM-IV-TR axes

Coding of Multi-Axial Conditions

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• Removal of Axes • Dimensional/Spectrum Approach • Subtypes and Specifiers • ICD 9 and ICD 10 Codes

What’s New in DSM-5

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Removal of Axes

• DSM-IV Axial System I clinical disorders II personality d/o, mental retardation III general medical condition IV psychosocial and environmental problems V GAF

• DSM-5: Axes are eliminated

Presenter

Presentation Notes

In the DSM-4, diagnoses were conducted along five axes. Axis I referred broadly to the principal condition that needed immediate therapeutic attention, such as a major depressive episode. Axis II included personality disorders and mental retardation. Axis III addressed any neurological or medical problem that might be relevant understanding the individual’s mental disorder or managing the mental disorder. For example, someone might have obstructive sleep apnea, leading to inadequate rest, which in turn could worsen the depressive episode. Axis IV covered recent psychosocial stressors; for example, a death in the family may have triggered the depressive episode. Under Axis V, the individual's Global Assessment of Functioning, or "level of function" which was assessed on a 0-to-100 scale.


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• Contributing psychosocial and environmental factors or other reasons for visits are now represented through an expanded selected set of ICD-9-CM V-codes ICD-10-CM Z-codes

Axis IV

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• The Global Assessment of Functioning (GAF) recommended for Axis V in the DSM-IV Multiaxial

assessment combined assessment of symptom severity,

dangerousness to self or others, self-care and social functioning into a single global assessment. used for determinations of medical necessity for

treatment by many payers, and eligibility for short- and long-term disability compensation

Axis V: Disability and Functioning

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Diagnosing

• Included Conditions to Diagnosis/Code Mental Health, Health Problems and Psychosocial

Stressors Psychosocial Stressors

● V - codes ICD 9 ● Z - codes ICD 10

Diagnosing disability and functioning levels ● WHODAS 2.0

Presenter

Presentation Notes

Instead of using a multi-axial system, List in the medical record mental disorders, health problems and psychosocial stressors that impact the diagnosis psychosocial stressors are found in an expanded list of V-codes in ICD-9. In the forthcoming ICD-10-CM, Z-codes will replace V-codes. V-codes and Z-codes used to indicate conditions and problems that impact diagnosis, course of the illness, prognosis treatment of a mental disorder If these conditions are part of the focus of treatment or explain the need for treatment or evaluation they can be used along with the mental-disorder code. These expanded codes can also be included in the patient's record to provide information about circumstances that may impact the care provided.


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• The best current measure of disability for routine clinical use.

• Based on the International Classification Of Functioning, Disability, and Health (ICF)

• Applicable to patients with any health condition • Brings DSM-5 into greater alignment with other medical

disciplines • Consistent with WHO recommendations move toward a clear conceptual distinction between

the disorders contained in the ICD and the disabilities resulting from disorders described in the ICF

WHO DAS 2.0

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• Clinicians should continue to assess the risk of suicidal and homicidal behavior APA’s Clinical Practice Guidelines for Suicidal

Behaviors • Use available standardized assessments for symptom

severity, diagnostic severity, and disability such measures included in Section III of DSM-5 can help with coding sub-types and specifiers

APA Recommendations

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Coding

• Criteria new or different

• Codes the same • ICD-10

Presenter

Presentation Notes

Although criteria have changed for many diagnosis and there are new diagnoses in DSM 5, the codes (which are taken from the ICD-9) have not changed and can be used for medical records and billing purposes. Starting October 1, 2014, ICD-10 codes will be used for coding mental health diagnosis. You will notice that the ICD 9 codes are in the manual with the ICD-10 code, in parenthesis, next to it.


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• Occasionally necessary to use the same code for more than one disorder DSM-5 diagnostic codes are limited to those

contained in the ICD some disorders must share codes for recording and

billing purposes ● hoarding disorder and obsessive-compulsive disorder

share the same codes (ICD-9-CM 300.3 and ICD-10-CM F42)

the DSM-5 diagnosis should be always be recorded by name in the medical record in addition to listing the code

Duplicate Codes

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• DSM-5 codes are limited to those contained in the ICD new DSM-5 disorders assigned the best available ICD codes sometimes names do not match the DSM-5 names For example

● DSM-5 disruptive mood dysregulation disorder (DMDD) is not listed in the ICD

● best ICD-9-CM code available for DSM-5 use was 296.99 (other specified episodic mood disorder)

● ICD-10-CM the code will be F34.8 (other persistent mood [affective] disorders)

• APA will work with CDC-NCHS and CMS to include new DSM-5 terms in the ICD-10-CM

DSM-5/ICD-9 Names Don’t Match

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• Companion publications DSM-5 contains the most up-to- date criteria for

diagnosing mental disorders ● includes extensive descriptive text ● provides a common language for clinicians to communicate

about their patients

ICD contains the code numbers used in DSM-5 and all of medicine and needed for ● insurance reimbursement ● monitoring of morbidity and mortality statistics by national

and international health agencies

ICD-9 and DSM-5

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Assessing on a Spectrum

• A dimensional approach • Assess severity No line between normal and

disordered Disorders are on a spectrum Measure degree of acuteness

• Examples Autism Spectrum Disorder Substance Use Disorder

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Presenter

Presentation Notes

A dimensional approach Mental illnesses, like most human problems, have many and varied causes and symptoms DSM-5’s Diagnostic Spectra Study Group had a goal to develop a dimensional approach to diagnosing. They looked for new associations within diagnostic categories sharing of symptoms across disorders sharing of causality of symptoms between diagnostic categories Assess severity Allows assessment of the severity of a condition It implies that there is not a solid line between what is considered normal and was is considered disordered, instead, we can assess the level of severity on a spectrum from few or no symptoms (no diagnosis) to mild, moderate and severe symptoms. It is being used with several diagnoses Disorders on a Spectrum This allows for measuring the degree of acuteness EXAMPLE: Most well known and controversial is the Autism Spectrum Disorder The change from separate disorders to one disorder on a spectrum was determined by research stated that these disorders were related conditions along a single continuum of behavior with symptoms ranging from mild to severe. The spectrum allows clinicians to account for variations from person to person. EXAMPLE: substance use disorder Abuse and Dependence are combined into a single spectrum and a severity measure is given based on the number of symptoms


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Assessing on a Spectrum

• Benefits More info = more insight Reduced use of NOS Informative and helpful for treatment planning Dont have to fit precisely into a category Research Hypothesizing and testing

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Presenter

Presentation Notes

Benefits of Assessing on a Spectrum There are many benefits of this new method is: helps clinicians gather more info and develop more insight to use when creating a treatment plan reduces the frequency of the use of “not otherwise specified”: as greater depth of detail about symptoms are collected — instead of simply marking them as present or absent. diagnoses are both more informative and helpful in treatment planning. Patients often do not fit precisely into one category or another, and the use of a spectrum in DSM-5 mitigates that problem. benefits research because the data it produces is more reliable, stable and valid. Spectrum models are also preferred for hypothesis development and testing


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Subtypes and Specifiers

• Provide increase specificity when diagnosing • Found in Classification Section • Most subtypes and specifiers cannot be coded using ICD-9

or ICD-10 Some subtypes or codes are available in ICD-10, will be

able to use that after October 2014. Write the subtype or specifier next to diagnosis, if no

code available

Presenter

Presentation Notes

Provide increase specificity when diagnosing Found in Classification Section, very front of the manual Most subtypes and specifiers cannot be coded using ICD-9 or ICD-10 Some subtypes or codes are available in ICD-10, will be able to use that after October 2014. Write the subtype or specifier next to the diagnosis and code if no code available


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Subtypes Specifiers • Diagnostic subgroups • Can only fall into one

subgroup at at time • All the possible

subgroups are listed

• More than one specifier may be given at a time.

• Allows for defining more homogeneous subgroupings

• Individuals with the same disorder sharing features

• convey information relevant to management of the disorder

The Differences


Presenter

Presentation Notes

Subtypes: Diagnostic subgroups Can only fall into one subgroup at at time All the possible subgroups are listed Specifiers: not mutually exclusive or jointly exhaustive more than one may be given at a time allow for defining more homogeneous subgroupings of a disorder with individuals with the same disorder sharing certain features convey information relevant to management of the disorder


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Subtypes Specifiers Specify Whether Specify or Specify if Examples: Specify whether:

With depressed mood With anxiety With mixed anxiety and

depressed mood With disturbance of conduct With mixed disturbance of

emotions and conduct Unspecified

Examples: Specify symptom type Specify current severity


Presenter

Presentation Notes

Specify Whether When it states Specify Whether, a subtype is selects. This example is the subtypes for Adjustment Disorder When it says Specify or Specify if, select one of the subtypes It might be a symptom type or it could be a severity rating.


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Disorder Subtypes Specifiers Alcohol Use Disorder

• In early remission, in sustained remission • In a controlled environment • With perceptual disturbances • Current severity: mild, moderate or severe

Opioid Intoxication

• With perceptual disturbances • With use disorder mild • With use disorder, moderate or severe • Without use disorder

Tobacco Use Disorder

• On maintenance therapy, in a controlled environment

• Current severity


Presenter

Presentation Notes

Substance Related Disorders Specifiers only


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NOS

• Replaced by Other Specified Unspecified

• Examples: Unspecified Eating Disorder Other Opioid-Induced Disorders

• The term "unspecified" is an option for most categories of disorders,

Presenter

Presentation Notes

1. In order to maintain greater concordance with the official International Classification of Diseases (ICD) coding system, Other Specified and Unspecified Disorders replaces NOS in the DSM-5 This is not a new specific mental disorder. The APA concluded this specifier was being overused as a shortcut, substituting for more-careful diagnosis. For example, research showed that more than half of all people diagnosed with eating disorders had NOS diagnoses. 2. The term "unspecified" is an option for most categories of disorders, such as "Unspecified Eating Disorder" or "Unspecified Alcohol-Related Disorder." 1. In order to maintain greater concordance with the official International Classification of Diseases (ICD) coding system, Other Specified and Unspecified Disorders replaces NOS in the DSM-5 This is not a new specific mental disorder. The APA concluded this specifier was being overused as a shortcut, substituting for more-careful diagnosis. For example, research showed that more than half of all people diagnosed with eating disorders had NOS diagnoses. 2. To enhance accuracy of diagnoses, NOS are replaced by “Other Specified” and “Unspecified.” The other specified disorder category is to allow clinicians communicate the specific reason that the presentation does not meet the criteria for any specific category within a diagnostic class. Example: name of the dx followed by the specific reason. For Example, “other specified depressive d/o, depressive episode with insufficient symptoms.” If the clinician chooses not to specify the reason that the criteria are not met for a specific disorder, then “unspecified depressive disorder” would be diagnosed. It’s a clinical decision The term "unspecified" is an option for most categories of disorders, such as "Unspecified Eating Disorder" or "Unspecified Alcohol-Related Disorder."


202.684.7457

• Clinicians may use DSM-5 in their practices immediately may be brief delays while insurance companies

update their claim forms and reporting procedures clinicians should use DSM-IV-TR diagnoses and codes

when required by a specific company • Transition to DSM-5 by the insurance industry should be

completed by December 31, 2013 • Need to be updates of questions in board

certification examinations and quality assessments for medical record review

Adoption of DSM-5

25

national council for behavioral health · includes extensive descriptive text provides a common...

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