ICD-10-CM Psychological and Behavioral Disorders Regulatory Requirements and Relationship to Clinical Use of DSM-5 Diagnostic Criteria Scott D. Daubert, Ph.D. VP, Operations Agenda • Overview, introduction and history of ICD-10. • The ICD-10-CM. • Differences between ICD-9-CM and ICD-10-CM structures. • Framework of the ICD-10-CM. • Clinical descriptions and diagnostic guidelines: • DSM-IV-TR and DSM-5. • WHO guidelines. • Preview of ICD-11. 1 ICD-9 History and Overview • The World Health Organization (WHO) developed ICD-9 for use worldwide: • Global, cooperative statistical effort to report and improve public health. • The U.S. developed “clinical modification” (ICD-9-CM). • Implemented in 1979 in the U.S. • Expanded number of diagnosis codes. • Developed procedure coding system. • ICD-9-CM diagnoses — used by all types of providers. • ICD-9-CM procedures — used only by inpatient hospitals. • Impact for PerformCare is limited to diagnoses. 2 ICD-9 History and Overview • What is ICD-9-CM used for? • Calculate payment — Medicare Severity-Diagnosis Related Groups (MS-DRGs). • Adjudicate coverage — Diagnosis codes for all settings. • Compile statistics — Original reason for WHO global standards. • Assess quality — Diagnoses is a important component of directing treatment. • ICD-9-CM is outdated: • 30 years old — Technology has changed. • Many categories full. • Not descriptive enough, not intuitive in organization. • What characteristics are needed in a coding system? • Flexible enough to quickly incorporate emerging diagnoses and procedures. • Exact enough to identify diagnoses and procedures precisely. • ICD-9-CM is neither of these. 3 ICD-10 History and Overview • 1990 — Endorsed by World Health Assembly (diagnosis only). • 1994 — Release of full ICD-10 by WHO. • 2002 (October) — ICD-10 published in 42 languages (including six official WHO languages). • Implementation: • 138 countries for mortality. • 99 countries for morbidity. • January 1, 1999 — U.S. implemented for mortality (death certificates). • 95% of the world’s health professionals already use ICD-10. 4 Countries Using ICD-10 For Reimbursement or Case Mix • United Kingdom (1995) • Nordic countries (Denmark, Finland, Iceland, Norway, Sweden) (1994 – 1997) • France (1997) • Australia (1998) • Belgium (1999) • Germany (2000) • Canada (2001) 5 Structural Differences — ICD-9-CM Diagnoses • ICD-9-CM has three to five digits. • Chapters 1 – 17: All characters are numeric. • Supplemental chapters: First digit is alpha (E or V), remainder are numeric. • Examples: • 311 — Depressive disorder not elsewhere classified. • 296.32 — Major depressive affective disorder recurrent episode moderate degree. • V61.20 — Counseling for parent-child problem unspecified. 6 Structural Differences ICD-10-CM Diagnoses • ICD-10-CM has three to seven digits: • Digit 1 is alpha (A – Z, not case sensitive). • Digit 2 is numeric. • Digit 3 is alpha (not case sensitive) or numeric. • Digits 4 – 7 are alpha (not case sensitive) or numeric. • If there is a decimal, it is always after the 3rd character. • ICD-9-CM has 14,025 codes, while ICD-10-CM has 68,069 codes. • Examples: 2014 ICD-10-CM Code F70 F31.2 F20.0 2014 ICD-10-CM Description Mild intellectual disabilities. Bipolar disorder, current episode manic severe with psychotic features. Paranoid schizophrenia. DSM-5 Description Intellectual disability (intellectual developmental disorder), mild. Bipolar I disorder, current or most recent episode manic, with psychotic features. ICD-9-CM Code 319 296.44 295.30 F20.9 Schizophrenia, unspecified. Schizophrenia. F11.221 Opioid dependence with intoxication delirium. Opioid Intoxication delirium, with moderate or severe use disorder. 295.90 292.81 7 Framework of the ICD-10-CM • 21 chapters in the list of diseases and injuries: • Chapter 1 — Certain infectious and parasitic diseases (A00 ‒ B99). • Chapter 2 — Neoplasms (C00 ‒ D49). • Chapter 3 — Disease of the blood and blood-forming organs and certain disorders involving the immune mechanism (D50 ‒ D89). • Chapter 4 — Endocrine, nutritional and metabolic diseases (E00 ‒ E89). • Chapter 5 — Mental, behavioral and neurodevelopmental disorders (F01 – F99). • Continues to Chapter 21… • All of the mental and behavioral disorder codes begin with the letter F. • Although there is room for up to seven characters, most of the BH disorders have four or five total characters. 8 Pause for Questions 9 Framework within Chapter 5, Behavioral Health, F codes ICD-10-CM Code Range Description F01 ‒ F09 Mental disorders due to known physiological conditions. F10 ‒ F19 Mental and behavioral disorders due to psychoactive substance abuse. F20 ‒ F29 Schizophrenia, schizotypal, delusional, and other non-mood psychotic disorders. F30 ‒ F39 Mood (affective) disorders. F40 ‒ F48 Anxiety, dissociative, stress-related, somatoform, and other non-psychotic mental disorders. F50 ‒ F59 Behavioral syndromes 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 disabilities. F90 ‒ F98 Behavioral and emotional disorders with onset usually occurring in childhood or adolescence. F99 Unspecified mental disorder. 10 Clinical Descriptions and Diagnostic Guidelines (DSM-IV and DSM-5) • As of Oct. 1, 2014, the ICD-10-CM code set is the HIPAA-adopted standard, and required for reporting diagnosis for dates of service on or after Oct. 1, 2014. (Delayed again until Oct. 1, 2015.) • Neither the DSM-IV nor DSM-5 is a HIPAA-adopted code set, and may not be used in HIPAA standard transactions (e.g., claims). • DSM-5 is “compatible” with both ICD-9-CM and ICD-10-CM. • The DSM-5 manual provides a crosswalk to both sets of codes. • There is no published (APA) DSM-IV direct crosswalk to ICD-10-CM. • The Oct. 1, 2015, date does not mandate clinical use, but such use must be translated to ICD-10-CM as of that date. 11 An Example of a Crosswalk Discrepancy A case of agoraphobia with panic disorder: • DSM-5 diagnosis of agoraphobia. • ICD-10-CM crosswalk = F40.00, Agoraphobia, unspecified. • DSM-5 diagnosis of panic disorder. • ICD-10-CM crosswalk = F41.0, Panic disorder [episodic paroxysmal anxiety] without agoraphobia. • There is no DSM-5 category that combines agoraphobia with panic disorder. • In ICD-10-CM, F40.01 = Agoraphobia with panic disorder. 12 ICD-11 and the WHO CDDG • Clinicians need guidance for making diagnoses beyond just having a code set. • This has been the role of the DSM publications, but only in the United States. • The Blue Book, published by the WHO (1992): • • • • • • The ICD-10 Classification of Mental and Behavioral Disorders: Clinical Descriptions and Diagnostic Guidelines (CDDG). Explicitly removed from use in the United States. Not part of ICD-10-CM. http://www.who.int/classifications/icd/en/bluebook.pdf. The CDDG is being updated for ICD-11. WHO adoption of ICD-11 is scheduled for 2015. • WHO opinion of DSM-5: • The definition of disease “cannot be legitimately managed by a single professional organization representing a single health discipline in a single country with a substantial commercial investment in its products.” Goodheart, Carol D. (2014) A Primer for ICD-10-CM Users. 13 Summary • Dates of service on or after October 1, 2015. • F Codes = Behavioral health. • Further subdivision of F Codes 01 ‒ 99. • Minor incompatibilities between DSM-5 and ICD-10-CM. • Many more diagnostic options in ICD-10-CM. • Not all DSM-5 diagnoses are F category, or behavioral health. • PerformCare next steps: • Issuance of provider notice and crosswalk. • IS system upgrades. • Testing with trading partners. 14 Web Resources CMS: • General ICD-10 information (including regulations) http://www.cms.hhs.gov/ICD10. CDC: • General ICD-10 information and mapping http://www.cdc.gov/nchs/icd/icd10cm.htm. DPW: • General ICD-10 information and FFS implementation http://www.dpw.state.pa.us/provider/icd10information/index.htm. 15 Questions? Contact presenter with additional questions: Scott Daubert, Ph.D. VP, Operations PerformCare sdaubert@performcare.org 717-671-6535 www.performcare.org 16 17