All Diagnosis Codes Changing October 1, 2015 to ICD-10 Codes
By Barbara Griswold, LMFT (Updated September 7, 2015)
The DSM-5 came out in 2013, and some of us are still getting used to changes in some of our most frequently-used diagnoses. Well hang on, and spread the word: ALL diagnosis codes are changing on October 1, 2015. This affects ALL therapists, both network providers and out-of-network providers.
First, a little context: The World Health Organization keeps an extensive list of all medical diagnoses and their codes called the International Classification of Diseases (ICD). Now think of the DSM, which is a list of diagnoses from the American Psychiatric Association. What’s the overlap? While the APA chose the diagnoses, the codes in the DSM are ICD codes. So you’ve been using ICD codes all along, probably without knowing it.
The DSM codes we have been using are from the ICD-Ninth Edition, or ICD-9, but for all session dates October 1, 2015 and after, you must transition to the ICD’s most recent diagnosis code list called the ICD-10. To clarify: The diagnoses themselves aren’t changing, just the codes.
Why are they changing? Actually, we are one of the last developed nation to make the transition to the new codes list. There are several goals here: First, to update the outdated and 30-year old code list. Second, to allow for more diagnoses: the current ICD-9 list of 14,000 diagnosis codes will increase to 69,000 medical and psychiatric codes. Third, there was a desire to communicate more with each code. The new codes allow for more “specificity” or detail to be communicated. For example, where before a clinician could diagnose a broken arm, now there would be different codes for a broken right arm and a broken left arm, as well as different codes depending on level of severity or recovery. Finally, a more detailed shared international coding system would improve analysis of health trends.
Here’s some good news: For each diagnosis in the DSM-5 you will see listed both the current ICD-9 for use prior to October 1st, followed by the new ICD-10 code in parentheses, starting with a
However, whether to use the DSM-5 as your coding source is controversial (more on this later in the article).
Tips for coding/diagnosing:
- Don’t include parentheses on the claim.
- Don’t write the diagnosis name on the claim.
- Don’t list both ICD-9 and ICD-10 diagnosis codes on the same claim form or superbill.
- Remember: the date of service determines which codes to use. Use ICD-9 codes for dates of service prior to October 1st, and ICD-10 codes for sessions October 1st and after. Don’t put pre-October dates of service on the same claim form as sessions October 1st and after.
- Many plans won’t pay if you only list a “phase of life issue “or relationship issue (what was a V-code in the ICD-9, now a Z-code in the ICD-10).
- Avoid “Unspecified” diagnoses, as plans may not reimburse for them — plans are looking for increasing specificity in diagnosis. When you have the choice between an “Unspecified” and “Other Specified” diagnosis, choose the latter, and document in the chart what criteria were not met for you to use another diagnoses of this category.
On the CMS-1500 form
- Put diagnoses in Box 21. List up to 12 codes.
- In the the upper right-hand corner of Box 21 where it says “ICD-Ind” (ICD Indicator), for sessions starting October 1st you should put a “0” (not a “10”) where you currently put a 9 — between the vertical dashed lines — to indicate you are using the ICD-10.
- According to the National Uniform Claim Commission who makes the CMS-1500, you should drop out the decimal point in the diagnosis (ex. 43.10 should become F4310 on your claim). See complete form info at www.tinyurl.com/deletedecimal
Seem simple? Think again. It turns out the ICD-10 code list doesn’t always match up to the ones in the DSM. There are a number of significant differences between the codes in the DSM-5 and the ICD-10 code list. There are DSM diagnoses you will not find if you search the ICD-10 code list (ex. Hoarding and Binge Eating Disorder). Or the same code can have very different titles: Alcohol “abuse” and “dependence” are diagnoses in the ICD-10, but these terms don’t exist in the DSM-5. And there are even ICD-10 codes that don’t appear in the DSM-5. For example, in the DSM-5, the transition to the new code for PTSD looks simple — F43.10 (see picture above). However, the official ICD-10 code list shows that same code — 43.10 — listed as “PTSD Unspecified,” and lists two other codes (PTSD Acute and PTSD Chronic) that are not in the DSM-5 (see picture). This could have serious consequences because many health plans are saying they won’t reimburse for “Unspecified” diagnoses. Another example: using the DSM-5, Paranoid Schizophrenia would fall into the catch-all Schizophrenia code of F20.9; However, using the ICD-10, this code is listed as “Schizophrenia, Unspecified” and Paranoid Schizophrenia has a separate code of F20.0. These are just a few of the many places where the DSM and ICD don’t align, and it is causing a great deal of confusion.
So, should you use the DSM-5 or ICD-10 list as your coding resource? I wish I could give a clear answer. While I recommend you contact the plan you are billing to see which code set they are using, most insurance plan representatives are not aware of the differences, so won’t understand your question. I discussed the issue with Debbie Court, Director of Provider Communications for Behavioral Network Services at Optum/United Behavioral Health. “Some [benefit plans] may not provide coverage for a condition included in the DSM, while others may provide coverage for conditions that are NOT included in the DSM. Optum uses DSM-5 as our basis for clinical interactions,” said Court. “In general, behavioral health providers should continue to follow the established industry practice of using the current edition of DSM to assess and bill.” She suggests providers make use of the Alphabetical Listing of Diagnoses in the back of the DSM-5, which lists both the ICD-9 and ICD-10 codes for each.
However, one ICD-10 expert and consultant I spoke with cautioned providers against relying solely on the DSM-5. She suggests that providers should educate themselves on the ICD-10 and all the ways it doesn’t align with the DSM-5, so they are making knowledgeable decisions about diagnosis, billing and documentation. She advises that — unless otherwise instructed by the health plan — providers should use the ICD-10 code list in billing and documentation, because the ICD-10 is mandated by HIPAA, and because the DSM-5 has many coding omissions and errors.
So what should you do to prepare for the transition?
- On October 1st, change all diagnoses in your client charts and billing software/databases. If your billing service tells you “just give us your diagnosis and we’ll convert them to ICD-10 codes” don’t allow it. You need to be responsible for your diagnoses and understanding the implications of the codes you use.
- If you use claims software, a claims clearinghouse, or a billing service, make sure it is ready for the transition. Ask where they are getting their codes. (continued)
- Purchase a DSM-5, but also get a complete list of the ICD-10 codes. While the list is available for free all over the internet at website such as www.icd10data.com, the most trusted/official list is available at http://tinyurl.com/icd10list (click on “2016 Code Tables and Index” and then click “Tabular” pdf).
“I thought the Codes just changed in 2013?” Those were the CPT Codes, which are the codes for the type of therapy provided (couple/family, intake, psychotherapy 45 minutes, etc), not for diagnoses. They are unrelated.
There won’t be a grace period. While you may have heard about a Congressional bill sponsored by that would require the Center for Medicare and Medicare Services (CMS) to accept both ICD-9 and ICD-10 codes for 180 days after the transition, the CMS asserts that is not technically possible.
For more information on working with the new codes, come to one of my trainings — see schedule at www.theinsurancemaze.com/workshops
Barbara Griswold, LMFT is the author of Navigating the Insurance Maze: The Therapist’s Complete Guide to Working with Insurance – And Whether You Should, now out in it’s 2015 6th edition and available for order at www.theinsurancemaze.com/store. She has a private practice in San Jose, California, and she invites you to contact her with your insurance questions and problems at firstname.lastname@example.org
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