Who's Afraid of the Big Bad Audit?
by Leigh-Ann Renz & Donna Koger, 10.15.15
How do ICD-10 & DSM-5 affect audits? What happens if you receive the dreaded audit notification? What are the guidelines for using DSM-5 and ICD-10 codes in preparation for potential audits? Fortunately, we have answers . . .
DSM-5, ICD-10, and Mental Health Audits
Two huge industry shifts that greatly affect audits have taken place for mental & behavioral health: DSM-5 and ICD-10. Mental health is the only industry that uses an endorsement guide for correctly assigning diagnosis codes, perhaps because testing for behavioral health concerns can be more amorphous. While the rest of the medical world is only concerned with the World Health Organization (WHO)’s ICD codes, behavioral health relies on the DSM to pick the correct ICD diagnosis code.
However, this can lead to confusion, as mental health providers often think that they are two separate lists (see “ICD-10 doesn’t affect me because we use DSM-5” for details). It’s also confusing because the DSM-5 doesn’t recognize or endorse all of the ICD codes that the WHO offers. A great example is F84.1, Atypical Autism: while this code is listed in the WHO’s ICD-10 manual, it’s not in the DSM-5. The APA has decided not to endorse that code at this time and lists only one code for autism (with multiple combinations of specifiers): F84.0, Autism Spectrum Disorder.
CMS states: “Since DSM-IV only contains ICD-9-CM codes, it will cease to be recognized for criteria or coding for services with dates of service of October 1, 2015 or later”, and the APA set a deadline of 1.1.14 for transitioning from DSM-IV to DSM-5! If a mental health provider uses code F84.1, Atypical Autism, they may get dinged on an audit, if that payer is following similar DSM-5 deadlines.
Another area of potential audit failure is not having enough supporting documentation in the clinical note. While every CPT code requires an appropriate ICD diagnosis code to support the action that was taken, certain payers will require more in-depth coding for clinical necessity than others. A claim may have enough of a diagnosis to be paid, but depending on the payer’s criteria, might be penalized during an audit.
For example, let’s say that a provider uses ICD diagnosis code F31.12, Bipolar I Disorder, in a clinical note, along with CPT code 90792 for a psychiatric hospitalization (ie, initial psychiatric evaluation done with medical evaluation and management). During an audit, the payer pulls that clinical note and sees that the provider used only the diagnosis code above, without any specifiers.
The payer may say that the diagnosis is actually not substantial enough to support a psychiatric hospitalization, and that either the diagnosis code itself needs to contain stronger specifiers (ie, “Bipolar I Disorder, Current or most recent episode manic, Severe; With peripartum onset”) and/or that those specifiers need to be listed in the body of the note in order to justify hospitalization.
Mental Health Answers to Many
All of this also means that mental health providers have to answer to several different bodies: a) CMS, if they accept Medicaid and/or Medicare reimbursements; b) other payers, who may stipulate that only DSM-5 is acceptable for diagnosing and that DSM-IV is no longer accepted; c) the WHO, which determines these codes to start with; and d) the APA, which decides which of the WHO codes will or won’t be endorsed in the DSM.
A practice may not have any issues with an audit conducted by a payer that allows them to use both DSM-IV and DSM-5 – but the same items reviewed may create a payback situation with an audit with another payer, if that payer no longer supports diagnosing with DSM-IV. It’s crucial for practices to be in close contact with their payers and nail down these types of stipulations in order to pass all of their audits.
One Last Tip
Make sure that you have renewed your contract with your payers to reflect the use of ICD-10 codes as of 10.1.15. Most payer contracts stipulate that ICD-9 codes will be used, and they should be updated or amended to reflect the replacement by ICD-10 codes for dates of service 10.1.15 and after. Click here for details.
“I recently had an audit and Department of Health & Mental Hygiene commented that PIMSY is one of the easiest and most effective Electronic Medical Record systems that they have ever encountered while performing mental health audits." - Melissa H., Owner & LCSW-C