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ICD-10-CM Psychological and Behavioral Disorders Regulatory Requirements and Relationship to Clinical Use of DSM-5 Diagnostic Criteria Scott D. Daubert,

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Presentation on theme: "ICD-10-CM Psychological and Behavioral Disorders Regulatory Requirements and Relationship to Clinical Use of DSM-5 Diagnostic Criteria Scott D. Daubert,"— Presentation transcript:

1 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

2 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

3 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

4 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 ICD-9-CM is outdated: 30 years old — Technology has changed.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

5 ICD-10 History and Overview 1990 — Endorsed by World Health Assembly (diagnosis only) — Release of full ICD-10 by WHO (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

6 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

7 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 — Major depressive affective disorder recurrent episode moderate degree. V61.20 — Counseling for parent-child problem unspecified. 6

8 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: ICD-10-CM Code 2014 ICD-10-CM DescriptionDSM-5 DescriptionICD-9-CM Code F70Mild intellectual disabilities.Intellectual disability (intellectual developmental disorder), mild. 319 F31.2Bipolar disorder, current episode manic severe with psychotic features. Bipolar I disorder, current or most recent episode manic, with psychotic features F20.0Paranoid schizophrenia F20.9Schizophrenia, unspecified.Schizophrenia F11.221Opioid dependence with intoxication delirium. Opioid Intoxication delirium, with moderate or severe use disorder

9 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

10 Pause for Questions 9

11 Framework within Chapter 5, Behavioral Health, F codes ICD-10-CM Code RangeDescription F01 ‒ F09Mental disorders due to known physiological conditions. F10 ‒ F19Mental and behavioral disorders due to psychoactive substance abuse. F20 ‒ F29Schizophrenia, schizotypal, delusional, and other non-mood psychotic disorders. F30 ‒ F39Mood (affective) disorders. F40 ‒ F48Anxiety, dissociative, stress-related, somatoform, and other non-psychotic mental disorders. F50 ‒ F59Behavioral syndromes associated with physiological disturbances and physical factors. F60 ‒ F69Disorders of adult personality and behavior. F70 ‒ F79Intellectual disabilities. F80 ‒ F89Pervasive and specific developmental disabilities. F90 ‒ F98Behavioral and emotional disorders with onset usually occurring in childhood or adolescence. F99Unspecified mental disorder. 10

12 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, (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

13 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

14 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. The CDDG is being updated for ICD-11. WHO adoption of ICD-11 is scheduled for 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

15 Summary Dates of service on or after October 1, 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

16 Web Resources CMS: General ICD-10 information (including regulations) CDC: General ICD-10 information and mapping DPW: General ICD-10 information and FFS implementation 15

17 Questions? Contact presenter with additional questions: Scott Daubert, Ph.D. VP, Operations PerformCare

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