EHR and practice management for mental / behavioral health
PIMSY mental health EHR asks: are payers profiling you!?

Are Payers Profiling You!?

by Lisette Wright, 3.9.16

Are payers profiling you?! Not understanding all of the flavors of PTSD and/or Schizophrenia might be creating a mitigating risk you’re not aware of.

Profiling Metrics

With increasing utilization of technology, data-mining experts have exploded in their profiling of patients and provider organizations to mitigate risk to a payer’s profits.

The unquestioned utilization of an industry-standard manual when diagnosing PTSD may put you on the payer’s radar, and you may not have thought of the implications.

The Flavors of PTSD

Available PTSD Diagnoses:

When you submit a claim with a diagnosis code on it of “Unspecified,” the payer has computer algorithms set up to flag those claims. Some payers have rejected the PTSD-Unspecified diagnosis, stating they want a more specific diagnosis (this is actually a reasonable action on the payer’s part).

Other payers are letting it go, with an eye on strict enforcement after the one-year grace period is over (CMS gave everyone one-year leniency for transitioning to ICD-10 CM). Still others are keeping a file on you and your utilization of “unspecified” diagnoses. This is referred to as “Provider Profiling” or “Provider Metrics.”

Classification for Acute or Chronic PTSD

Neither classification system defines “Acute” or “Chronic.” Therefore, it is up to the provider organization to set up a clinical policy regarding the utilization, timeframes, and documentation elements required when diagnosing PTSD.

A simple example is to set up a clinical policy that says, “If symptoms persist for 0-3 months, then PTSD-Acute shall be coded. If symptoms persist for 3+ months, PTSD Chronic shall be coded.” Your policy should also include a section about the utilization of Unspecified diagnoses.

8 Varieties of Schizophrenia Versus 1

Another item of coding discrepancy concern: “A few weeks ago, CMS began denying coverage for the ‘DSM-5’ diagnosis of F20.9 Schizophrenia, Unspecified, at least that was the report from provider organizations.”  

Apparently, ICD-10-CM lists 8 different varieties of Schizophrenia, and there is only one listed in the DSM-5: F20.9! (There are two other related codes: F28, other specified schizophrenia spectrum and other psychotic disorder – and F29, unspecified schizophrenia spectrum and other psychotic disorder). 


“Providers will need the Tabular Index for  ICD-10-CM diagnoses, including codes in all 21 Chapters, for all billing, compliance, and documentation purposes.”

Going Forward

All practices considered HIPAA Covered Entities (CEs) are required to use ICD-10-CM in a fully compliant manner. Going forward, be prepared for challenges like these regarding true ICD-10 compliance. That includes using the most accurate diagnosis possible, not only to ensure thorough reimbursement, but also for optimal client care.

You want to be on the positive end of Profiling Metrics. Looking ahead, how might provider profiling affect your contracted rates, the contract itself, or your desirability compared to that of your competitor? What is your utilization rate of “unspecified” diagnoses, EBP, and tracking of consumer satisfaction/valuation?

What other diagnoses are making you susceptible to this practice? Behavioral Health Solutions can help you leverage your current EHR to collect and track this critical performance data. Ask us how!

lisette wright advisory

Lisette Wright, M.A., has over 20 years of experience in the health and human service industry. Her background includes providing clinical services as well as Health Information Technology Consulting services. After receiving her certificate in health information technology in 2011, she has worked exclusively with organizations helping them with EHR Selections, Functionality Assessments and Implementations, IT Assessments, Leveraging Data for Performance, Meaningful Use Program Development, and implementing Integrated Care Delivery Models. She presents nationally on the ICD-10/DSM-5, systems readiness, and provides project management oversight to organizations.




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