What’s Up Wednesday
Together Let’s Get ICD-10 Ready
Date: June 17, 2015
Time: 2 – 3 p.m.
Phone Number: 800-882-3610
Pass code: 5411307
Presented by the Pennsylvania Blues Plans
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What’s Up Wednesday and ICD-10

Increase
Collaboration, communication, education and coordination
between hospitals, physicians, payers and vendors

Expand
Understanding of the current state of ICD-10, recent regulatory
decisions and industry perspectives

Raise
Awareness and understanding of the unique challenges that
ICD-10 brings to the entire health care industry

Provide
Tools, techniques, best practices, and helpful hints that can be
used to support ICD-10 implementation
Please remember that during the call all attendees are on mute
except for any guest speakers and panelists.
Please e-mail any questions you would like addressed during or after the call to
ICD10ProviderCommunication@capbluecross.com.
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Today’s ICD-10 Agenda
 Insurance Implications of Implementation of DSM-5
 Kathleen C. Dougherty, M.D., D.F.A.P.A.
Chair, Dept. of Psychiatry, Lancaster General Health
Director, Behavioral Health Service Line, LGPA Behavioral Health
 AAPC – Information for getting ICD-10 Ready
 Rhonda Buckholtz VP, ICD-10, AAPC
CPC, CPMA, CRC, CPC-I, CHPSE
Insurance Implications of
Implementation of DSM-5
Kathleen C. Dougherty, M.D., D.F.A.P.A.
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DSM-5 Classification Criteria and Use Slides
courtesy of:
David J Kupfer, M.D.
Darrel A Regier, M.D., M.P.H.
William E Narrow, M.D.,
M.P.H.
American Psychiatric
Association
Conceptual Development of DSM
DSM-I
Presumed
etiology
DSM-5
New approaches considered
(dimensional,
spectra,
developmental, culture,
impairment thresholds,
living document)
DSM-III
Reconceptualization
Explicit criteria
(emphasis on reliability
rather than validity)
DSM-II
Glossary
definitions
DSM–IV
Requires clinically
significant distress
or impairment
DSM-III-R
Criteria broadened
Most hierarchies
dropped
Copyright © 2013. American Psychiatric Association.
DSM-5 Structure
• Section I: DSM-5 Basics
• Section II: Essential Elements: Diagnostic Criteria
and Codes
• Section III: Emerging Measures and Models
• Appendix (includes highlights of changes,
glossaries)
• Index
Copyright © 2013. American Psychiatric Association.
Section I
•
•
•
•
•
Brief DSM-5 developmental history
Guidance on use of the manual
Definition of a mental disorder
Cautionary forensic statement
Brief DSM-5 classification summary
Copyright © 2013. American Psychiatric Association.
DSM-5 Structure
• Section I: DSM-5 Basics
• Section II: Essential Elements: Diagnostic
Criteria and Codes
• Section III: Emerging Measures and Models
• Appendix (includes highlights of changes,
glossaries)
• Index
Copyright © 2013. American Psychiatric Association.
Changes in Specific DSM Disorder
Numbers; Combination of New, Eliminated,
and Combined Disorders
(net difference = -15)
Specific Mental
Disorders*
DSM-IV
DSM-5
172
157
*NOS (DSM-IV) and Other Specified/Unspecified (DSM-5) conditions are counted
separately.
Copyright © 2013. American Psychiatric Association.
New and Eliminated Disorders in DSM-5
(net difference = +13)
New Disorders
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Social (Pragmatic) Communication Disorder
Disruptive Mood Dysregulation Disorder
Premenstrual Dysphoric Disorder (DSM‐IV appendix)
Hoarding Disorder
Excoriation (Skin‐Picking) Disorder
Disinhibited Social Engagement Disorder (split from Reactive Attachment
Disorder)
Binge Eating Disorder (DSM‐IV appendix)
Central Sleep Apnea (split from Breathing‐Related Sleep Disorder)
Sleep-Related Hypoventilation (split from Breathing‐Related Sleep Disorder)
Rapid Eye Movement Sleep Behavior Disorder (Parasomnia NOS)
Restless Legs Syndrome (Dyssomnia NOS)
Caffeine Withdrawal (DSM‐IV Appendix)
Cannabis Withdrawal
Major Neurocognitive Disorder with Lewy Body Disease (Dementia Due to
Other Medical Conditions)
Mild Neurocognitive Disorder (DSM‐IV Appendix)
Eliminated Disorders
1. Sexual Aversion Disorder
2. Polysubstance‐Related Disorder
Combined Specific Disorders in DSM-5
(net difference = -28)
1. Language Disorder (Expressive Language Disorder & Mixed Receptive
Expressive Language Disorder)
2. Autism Spectrum Disorder (Autistic Disorder, Asperger’s Disorder,
Childhood Disintegrative Disorder, & Rett’s disorder—PDD-NOS is in the NOS
count)
3. Specific Learning Disorder (Reading Disorder, Math Disorder, & Disorder of
Written Expression)
4. Delusional Disorder (Shared Psychotic Disorder & Delusional Disorder)
5. Panic Disorder (Panic Disorder Without Agoraphobia & Panic Disorder With
Agoraphobia)
6. Dissociative Amnesia (Dissociative Fugue & Dissociative Amnesia)
7. Somatic Symptom Disorder (Somatization Disorder, Undifferentiated
Somatoform Disorder, & Pain Disorder)
8. Insomnia Disorder (Primary Insomnia & Insomnia Related to Another Mental
Disorder)
9. Hypersomnolence Disorder (Primary Hypersomnia & Hypersomnia Related
to Another Mental Disorder)
10. Non-Rapid Eye Movement Sleep Arousal Disorders (Sleepwalking
Disorder & Sleep Terror Disorder)
Copyright © 2013. American Psychiatric Association.
Combined Specific Disorders in DSM-5
(Continued)
(net difference = -28)
11. Genito‐Pelvic Pain/Penetration Disorder (Vaginismus & Dyspareunia)
12. Alcohol Use Disorder (Alcohol Abuse and Alcohol Dependence)
13. Cannabis Use Disorder (Cannabis Abuse and Cannabis Dependence)
14. Phencyclidine Use Disorder (Phencyclidine Abuse and Phencyclidine
Dependence)
15. Other Hallucinogen Use Disorder (Hallucinogen Abuse and Hallucinogen
Dependence)
16. Inhalant Use Disorder (Inhalant Abuse and Inhalant Dependence)
17. Opioid Use Disorder (Opioid Abuse and Opioid Dependence)
18. Sedative, Hypnotic, or Anxiolytic Use Disorder (Sedative, Hypnotic, or
Anxiolytic Abuse and Sedative, Hypnotic, or Anxiolytic Dependence)
19. Stimulant Use Disorder (Amphetamine Abuse; Amphetamine Dependence;
Cocaine Abuse; Cocaine Dependence)
20.Stimulant Intoxication (Amphetamine Intoxication and Cocaine Intoxication)
21. Stimulant Withdrawal (Amphetamine Withdrawal and Cocaine Withdrawal)
22. Substance/Medication-Induced Disorders (aggregate of Mood (+1), Anxiety
(+1), and Neurocognitive (-3))
Copyright © 2013. American Psychiatric Association.
Changes from NOS to
Other Specified/Unspecified
(net difference = +24)
NOS (DSM-IV) and
Other
Specified/Unspecified
(DSM-5)
DSM-IV
DSM-5
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65
Other Specified and Unspecified Disorders in DSM-5 replaced the Not
Otherwise Specified (NOS) conditions in DSM-IV to maintain greater
concordance with the official International Classification of Diseases
(ICD) coding system. This statistical accounting change does not signify
any new specific mental disorders.
Copyright © 2013. American Psychiatric Association.
DSM-5 Structure
• Section I: DSM-5 Basics
• Section II: Essential Elements: Diagnostic Criteria
and Codes
• Section III: Emerging Measures and Models
• Appendix (includes highlights of changes,
glossaries)
• Index
Copyright © 2013. American Psychiatric Association.
After Section III is the Appendix, which
includes:
• Highlights of Changes From DSM-IV to DSM-5
• Glossary of Technical Terms
• Glossary of Cultural Concepts of Distress
• Alphabetical Listing of DSM-5 Diagnoses and Codes
(ICD-9-CM and ICD-10-CM)
• Numerical Listing of DSM-5 Diagnoses and Codes
(ICD-9-CM)
• Numerical Listing of DSM-5 Diagnoses and Codes
(ICD-10-CM)
• DSM-5 Advisors and Other Contributors
Changes to the Multiaxial System
• DSM-5 combines all diagnoses onto a single axis
(previously Axes I-III).
• Contributing psychosocial and environmental
factors (previously Axis IV) or other reasons for
visits are now represented through an expanded
selected set of ICD-9-CM v codes and, from the
forthcoming ICD-10-CM, z and t codes.
Copyright © 2013. American Psychiatric Association.
Changes to the Multiaxial System
•
With Axis V eliminated, clinicians are no longer required to use
the Global Assessment of Functioning (GAF) Scale.
▫ GAF confounds symptom severity, risk of harm to self or
others, disability, and functioning and combines into a single
score.
•
Rather than use the single GAF score to reflect multiple areas of
concern, we have unpacked the GAF such that these items can be
documented separately.
▫ Risk of harm to self or others can be assessed through APA’s
Clinical Practice Guidelines
(http://www.psychiatry.org/practice/clinical-practiceguidelines).
Copyright © 2013. American Psychiatric Association.
DSM-5 and ICD Codes
•
DSM-5 and its ICD-9-CM codes became effective in May
2013 and can be used immediately.
•
ICD-10-CM codes do not go into effect until October 1, 2015.
•
ICD-9-CM codes are numerical and listed first. ICD-10-CM
codes are alphanumerical and listed second, in parenthesis.
Copyright © 2013. American Psychiatric Association.
DSM-5 and ICD Codes
•
Codes accompany each criteria set, but some codes are used
for multiple disorders.
▫ For example, hoarding disorder and obsessive-compulsive disorder
share the same codes (ICD-9-CM 300.3 and ICD-10-CM F42).
▫ Because of this, the DSM-5 diagnosis should be always be recorded by
name in the medical record in addition to listing the code.
•
For some disorders, unique codes are given for subtypes,
specifiers, and severity (e.g., major depressive disorder).
•
For neurocognitive and substance/medication-induced
disorders, coding depends on further specification.
Copyright © 2013. American Psychiatric Association.
Inconsistencies in DSM and ICD
Code Names
•
New ICD codes could not be given to new DSM-5 disorders;
instead, these new disorders were assigned the best available
ICD codes. The names connected with these ICD codes
sometimes do not match the DSM-5 names.
▫ For example, disruptive mood dysregulation disorder is
not listed in the ICD. The best ICD-9-CM code available
for DSM-5 use was 296.99 (other specified episodic mood
disorder). For ICD-10-CM the code will be F34.8 (other
persistent mood [affective] disorders).
Copyright © 2013. American Psychiatric Association.
New DSM-5 Diagnoses Code Issues
DSM-5 Disorder
Hoarding
Disorder
Excoriation
(Skin Picking)
Disorder
Binge Eating
Disorder (from
DSM-IV
Appendix)
Substance Use
Disorders
ICD-9ICD-9-CM
CM Code Title
300.3
Obsessive
Compulsive
Disorders
698.4
dermatitis
factitia
[artefacta]
307.51
bulimia nervosa
ICD-10CM Code
F42
ICD-10-CM Title
L98.1
factitial dermatitis
F50.2
bulimia nervosa
Obsessive
Compulsive Disorder
Coding will be applied based on severity: ICD codes associated with
substance abuse will be used to indicated mild SUD; ICD codes
associated with substance dependence will be used to indicate
moderate or severe SUD
Copyright © 2013. American Psychiatric Association.
Inconsistencies in DSM and ICD Code Names
• APA will be working with CDC/NCHS and CMS to
include new DSM-5 terms in the ICD-10-CM and
will inform clinicians and insurance companies
when modifications are made.
• Because DSM-5 and ICD disorder names may not
match, the DSM-5 diagnosis should always be
recorded by name in the medical record in
addition to listing the code.
Copyright © 2013. American Psychiatric Association.
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DSM-5 Coding inaccuracies
• Due to a variety of factors:
▫ Actual text errors
▫ Coding changes
▫ Need to check website
for updates
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Important Insurance Considerations
•
There may be some delay for certain insurance carriers to
update their coding systems
•
Similar delays may exist for removing the multiaxial format
from forms and computer systems
▫ Place all mental and other medical disorders on a single list—with
ICD code and name of disorder
▫ In place of Axis IV, use DSM-5’s v/z/t codes
▫ WHODAS 2.0 provided for disability rating (formerly Axis V), but no
replacement for the GAF has been approved as of yet
Copyright © 2013. American Psychiatric Association.
Further Questions?
• For more information about CMS acceptance of
DSM-5 and ICD-9-CM and ICD-10-CM codes, visit
their online FAQ at:
https://questions.cms.gov/faq.php?id=5005&faqId=1817
• For more information about DSM-5
implementation, a detailed Frequently Asked
Questions document can be found at
www.dsm5.org
Copyright © 2013. American Psychiatric Association.
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AAPC – Information for getting ICD-10 Ready
Rhonda Buckholtz VP, ICD-10, AAPC
Getting Prepared-Assessing Your Impact
• Perform a review of where all a diagnosis code
impacts your practice
• Forms
• Policies
• Administrative functions (precertification, prior
auths, referrals, etc)
• Contracts
• Documentation
Getting Prepared-What You Should Do Now
•
•
•
•
•
•
•
•
Engage heavily with vendors
Do you need hardware/software updates
When will the test
Budget for changes
Will require long term planning
Plan B
Devise a training plan
Every single person will need some level of
training
Productivity Issues
• Coders
▫ All must start back at the beginning
▫ Will take time to become familiar with the books
▫ Long code descriptors will take time to read and
assign for electronic use
• Clinicians
▫ Additional documentation will be necessary
▫ New concepts will take time to incorporate
▫ Long code descriptors will take time to read and
assigning for EMR use
ICD-10-CM Critical Concepts
•
•
•
•
•
•
Greater specificity
Unique coding changes from ICD-9-CM
Complete new system with ICD-10-PCS
Unspecified codes in ICD-10-CM
7th character extenders
Multitude of instructional notes
Education
• Proper training will be a large part of success
▫
▫
▫
▫
Plan early
Train in stages
Measure productivity and retention
Retrain when needed
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ICD-10
What’s in a Code?
Laterality
Unspecified….
Enhanced Clinical Conditions
Specificity….
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Dual Coding
Different Meanings
Productivity/Side by side
HIPAA exempt submissions
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Purpose of ICD
It’s not about reimbursement…… or is it?
• Documents the patient’s clinical condition
▫ Qualifies medical necessity
▫ Helps meet quality measures
▫ Enables services and procedures
Clinical Concepts
• Type
• Temporal factors
• Caused by/Contributing
factors
• Symptoms/Findings/Manife
stations
• Localization/Laterality
• Anatomy
• Associated with
• Severity
• Episode
• Remission status
• History of
•
•
•
•
•
•
•
•
•
•
Morphology
Complicated by
External Cause
Activity
Place of Occurrence
Loss of Consciousness
Substance
Number of Gestations
Outcome of Delivery
BMI
Specificity
• Laterality
• Temporal Factors
• Anatomic Location
• Complications/Manifestations
• Type
Assisting Providers with Transitio
• A real emphasis needs to be made with the
practitioners to move away from usage of
unspecified codes.
• There is a high risk for denial by payers under ICD10-CM for certain unspecified code usage.
Assisting Providers with Transition
• Template Assessments
▫ EMR
▫ Paper
• Update where necessary
• Educate on changes with time enough to
become familiar with them
Assisting Providers with Transition
• Documentation Assessments
▫ Compares current documentation against ICD-10CM specificity
▫ Run by entire practice
▫ Run by clinic/facility
▫ Run by provider
▫ Create a report
▫ Meet with provider
▫ Re-assess
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If You Have A Question….
If you have a question, please e-mail it to
ICD10ProviderCommunication@capbluecross.com
so we can address it during the call.
We would like to hear from you so please send your feedback to:
o
o
o
o
Capital BlueCross: ICD10PC@capbluecross.com
Highmark: ICD-10Inquiries@highmark.com
Independence BlueCross: icd10@ibx.com
BCNEPA: ICD10Inquiries@bcnepa.com
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Helpful Links
 Pennsylvania Medical Society
http://www.pamedsoc.org/
 The Hospital & Healthsystem Association of Pennsylvania
https://www.haponline.org/
 CMS (Center for Medicare & Medicaid Services
http://www.cms.gov/Medicare/Coding/ICD10/index.html?redirect=/icd10
 ICD-10 WATCH
http://www.icd10watch.com/
 ZIRMED – Innovating Connected Healthcare
http://icd.zirmed.com/
 WEDI
http://www.wedi.org/workgroups/icd-10
 ICD-10 HUB
http://www.icd10hub.com/
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Next What’s Up Wednesday Call
 Next What’s Up Wednesday Call:
 July 15, 2015 from 2 to 3PM EST
 Visit a PA Blue’s Plan website for more information:
 Capital BlueCross
https://www.capbluecross.com/wps/wcm/connect/cbc-public/cbc/forhealthprofessionals/icd-10/icd-10home
 Blue Cross Northeastern PA
https://www.bcnepa.com/Privacy/ICD-10.aspx
 Independence Blue Cross
http://www.ibx.com/providers/claims_and_billing/icd-10.html
 Highmark Blue Shield
https://prc.highmark.com/rscprc/hbs/pub?document=https%3A//www.highmarkblueshield.com/health/docume
nts/prof-pub/icd10-library.html
We would like to hear from you so please send your feedback to
ICD10ProviderCommunication@capbluecross.com
45
THANK YOU