EHR and practice management for mental / behavioral health
PIMSY mental health practice management software shares ICD-10 updates effective October 1, 2016

October 2016 ICD-10 Updates

by Leigh-Ann Renz, 10.15.16

CMS offered a grace period for the first year of ICD-10 by not denying claims that had codes in the correct ICD-10 “family”; that grace period ended on September 30, 2016 and is a game changer for all industries. Additionally, some diagnosis codes for mental / behavioral health have changed as of October 1, 2016.

Grace Period Over

“ICD-10 flexibilities were solely for the purpose of contractors performing medical review so that they would not deny claims solely for the specificity of the ICD-10 code as long as there is no evidence of fraud.” {CMS}

While the grace period only applied to Medicaid and Medicare reimbursements, via CMS, some commercial payers echoed it – but many did not offer this transition flexibility. It appears that the years of dire warnings and resulting preparation paid off: most studies show the rate of denials pretty much unchanged since the 2015 deadline. However, keep in mind that those low rates of denial might be dependent on the grace period!

“The ICD-10 family of codes will no longer be acceptable if a more specific ICD-10 code exists that best describes your patient’s condition.” {Denny Flint, Director of Operations, Peak MSO}

Code specificity is the new enforced standard. You must be proficient in using the most specific ICD-10 codes possible, or your revenue flow might take a hit as post-grace-period denials increase. See the details below about the changing ICD-10 / DSM-5 codes for mental + behavioral health, and make sure your clinicians are up to date with all of these October 2016 changes in policy. It all comes down to provider performance.

Not Just About Claims

As CMS and HHS shift the industry from quantity to quality-based metrics, it’s more important than ever to prove the necessity and quality of your treatments. Using the most accurate and specific ICD-10 code for diagnosis isn’t just about pushing the claim through for payment: it’s about providing the best quality of care possible for your clients – and proving that you’re doing so.

“The bottom line is that your reported ICD-10 codes are used in a multitude of ways to measure you against your peers.” {Denny Flint, Director of Operations, Peak MSO}

Watch Your Unspecified Codes

In addition to the need for greater code specificity presented by the end of the ICD-10 grace period, mental + behavioral health clinicians have already encountered some challenges with unspecified codes, due to incongruities between the DSM-5 and the CMS code sets. For example: whereas the DSM-5 only lists one option for PTSD (F43.10, PTSD-unspecified), CMS offers three codes. Same deal for Schizophrenia: DSM-5 offers one code (F20.9, Schizophrenia), while CMS provides ten options.

Clinicians are using the only codes they see available for PTSD and Schizophrenia in the DSM-5 – which are unspecified – and getting denied by payers due to lack of diagnosis code specificity! Remember: the DSM-5 is a guide to picking the right ICD-10 code. CMS has confirmed that clinicians can use unspecified codes when they are most appropriate; however, you must demonstrate medical necessity for the services provided.

“While you should report specific diagnosis codes when they are supported by the available medical record documentation and clinical knowledge of the patient’s health condition, in some instances signs/symptoms or unspecified codes are the best choice to accurately reflect the health care encounter. You should code each healthcare encounter to the level of certainty known for that encounter.” {CMS}

Changes for Mental / Behavioral Health

Not only do mental and behavioral health care providers have to contend with discrepancies between the DSM-5 and CMS code sets – and the end of the grace period – there are several ICD-10 that are actually changing for psychology and psychiatry! See the chart below for details from the APA.

In addition, many of the DSM-5 code descriptions have changed too: click here for a complete list of all of the APA / DSM-5 code and description updates you need to be in adherence with to be compliant

More Information

For more information, check out: ICD/DSM Resource Center, CPT Code Changes, and Mental / Behavioral Health Compliance Blog.

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Leigh-Ann Renz is the Marketing & Business Development Director of PIMSY EHR. For more information about electronic solutions for your practice, check out Mental Health Practice Management Software.

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