by Leigh-Ann Renz, 8/7/14 (revised & updated on 6.23.15)
How do you crosswalk DSM-IV, DSM-5, ICD-9 and / or ICD-10!?
We know: it’s confusing. And based on the questions our previous blog posts generated, we’re realizing it’s even more complicated than previously thought! So here’s a little clarification about ICD and DSM for mental & behavioral health care / substance usage providers:
There are no actual DSM-5 codes – but there kind of are….??
Here’s the deal: there are not 4 diagnosis code sets currently at hand; there are only 2: ICD-9 and ICD-10. These codes are established by the World Health Organization (WHO), and are therefore an international standard of diagnosis, including for mental / behavioral health and psychiatry. The rest of the world has been using ICD-10 for decades, while the US has continued to use ICD-9. Click here for an excellent article about the reasons to adopt ICD-10.
The Centers for Medicare and Medicaid (CMS) have mandated that mental health professionals follow the diagnosis guidance of DSM, a guide to the ICD codes, published by the American Psychiatric Association (APA). APA does not recognize certain ICD codes put out by WHO, but endorses other ICD codes, to be used for mental health diagnosis.
This means that DSM is the mental / behavioral health care provider’s (or psychiatrist’s) Bible, the industry-accepted standard for diagnosing in our field, while at the same time being required by CMS. In a sense, DSM is its own code set, because it is endorsing some ICD codes while not accepting others. But the codes themselves are the same.
What does DSM-5 actually provide?
DSM-IV, the recently replaced version, promoted ICD-9 diagnosis codes. DSM-5, the brand new version that was just put into effect by APA on 1/1/14, promotes both ICD-9 and ICD-10 diagnosis codes. This is because DSM-5 straddles the transition period between ICD-9 and ICD-10, which is scheduled to take effect on 10/1/15.
APA knew that providers would need to utilize both code sets during this transitional time: dates of service 10.1.15 and on will be diagnosed in ICD-10, while dates of service 9.30.15 and prior will be diagnosed in ICD-9. The DSM-5 lists “Tourette’s disorder” as 307.23 (F95.2). 307.23 is the ICD-9 code for this diagnosis; F95.2 is the ICD-10 code.
What about DSM-IV?
While the rest of the medical world grapples with immense challenges presented by the ICD-9 to ICD-10 transition, psychologists and psychiatrists have the additional burden of updating to DSM-5 diagnosis practices. The other big difference between DSM-IV and DSM-5 is that they provide different diagnosis pathways: some (ICD-9) codes have been excluded; others have been added; and often, the entire process of evaluating and diagnosing a client has changed.
The good news is that, once providers have learned these new diagnosis pathways, DSM-5 provides the ICD-10 codes, making it easier for professionals in our industry to make the 10/1/15 transition. But if someone is referring to codes as “DSM-5”, that’s an arbitrary reference: DSM-5 is a new guideline for coding, and it provides both the correct ICD-9 and ICD-10 codes to use.
If my payers say they require DSM-5 as supporting documentation, what should I do!?
Although the APA has not yet officially retired DSM-IV, mental & behavioral health care providers should have been using DSM-5 as of 1/1/14. What this means is that you should be using DSM-5 to diagnose, especially if your payers are requiring it, and this most likely includes a practice-wide training for all of your providers.
You’ll want to make sure than none of the expired ICD-9 codes are used (such as 293.9, mental disorder due to medical condition), and any new ICD-9 codes that have been added are used when appropriate. While DSM-IV and DSM-5 will sometimes guide providers to the same diagnosis, in other instances, they won’t – and the codes themselves are often much different now under DSM-5.
How do I make this work for my practice?
The easiest way to tackle this is to compile a list of your most frequently used diagnosis codes and create a guide for your staff. This means someone will have to sit down with the DSM-5, comb through it, and determine which changes (if any) affect your most commonly used codes. Then conduct practice-wide training with all of your employees, helping them to understand the changes. You’ll probably want to exclude the ICD-10 codes for now to help minimize confusion, but plan on utilizing a similar guide next summer when you begin testing ICD-10 codes with your payers.
Keep in mind: this is the psychologist's or psychiatrist’s responsibility, not the billing person’s!
While of course you want the billing staff to be on top of the changes, keep in mind that the diagnosis code is the responsibility and domain of the provider! One of the most common responses we hear is “Oh, the billing folks are going to take care of that” – wrong!! They can’t: only the provider can supply the diagnosis code, and trying to fix incorrect diagnosis codes can be a nightmare for the biller, provider and the client!
This means that your staff should consider endorsing and learning the new coding guidance in DSM-5, and be prepared to use it to switch to ICD-10 codes next year.
What about crosswalks between DSM-IV and DSM-5, or DSM and ICD? What should I consult??
Surprisingly, there aren’t many crosswalks available for psychology and psychiatry. While we’ve heard practices refer to Dr. Bob’s site, there’s not much information available online – perhaps because coding is such a tricky issue, and no one wants to assume responsibility for coding guidance.
Where can you turn? The DSM-5! While it’s time consuming to create your own crosswalk based on the codes you most commonly use, and although DSM-5 can be a little confusing, it still does a great job of spelling out the steps and codes. In essence, DSM-5 is an ICD-9 to ICD-10 crosswalk, because it’s providing both code sets for each diagnosis.
While there are plenty of trainings available for coding guidance that may be of great help to your organization, don’t forget to use the master book itself! It’s required by CMS and the only coding guidance available to providers in the US. Get a cuppa joe, snuggle in, and figure out how to make it’s consultation work for your practice.
Another great resource for the new ICD-10 codes for mental / behavioral health is the CMS Integrated Outpatient Code Editor (IOCE) - check out page 138 here.