Sunday, September 20, 2015

ICD-10-CM and the Panic that Numbers Ensue

For those of you who do not know the meaning of ICD-10-CM, it is the International Classification of Diseases, a lengthy clinical catalog system conjured up by the World Health Organization (WHO) to designate medical codes. Physicians and clinicians everywhere are bound by them, use theses codes for billing and diagnostic purposes. The ICD-10-CM replaces ICD-9 on October 1, 2015.

To bill, we need to code, and start with procedures. Your primary care doctor perfunctorily codes hundreds of procedures, ranging from removing a dot on your skin, to listening to lungs, heart beats, peeking down throats and wiggling toes. General check-ups might be called wellness visits, now, because things just have to keep changing.

Mental health professionals have only a few procedure codes, a handful, really. Is this an initial evaluation? Group or family therapy? A 15, 30, 45, or maybe a 52 minute-hour? There are a few more.

Then come the codes for diagnoses, naturally. Here's where mental health professionals choose from a considerably wide menu. In the diagram below you'll find some thirty new diagnoses per page, 21 pages in all beginning on page 839 of the appendix in the back of the DSM 5. Therapists tend to keep it simple, stick to basics, anorexia, ADHD, substance abuse and dependency, psychosis, depression, anxiety, autism, and the many variants of common constellations of complaints. But we shouldn't, there is so much more. Go up and down the alphabet, you name it, there is a code for something you never thought that much about before.
ICD-10 DSM-5 codes translated

And there might be a specifier. Is the disorder recurrent? Is it severe? Does it have an organic cause, or a severely anxious component? Are there hallucinations?

Etc. Rock on.

I owe my suite-mate mountains of gratitude, because for years she has provided me time to kvetch between patients. She gives me advice and empathy, and seduces me with candy to keep me awake on the job. But for six months, at least, she's been making meaningful eye contact as her patients slip into her office and I await mine. She'll look serious, and with a raise of both shoulders a slow shake of her head. She inhales deeply, then sighs before booming:
How are we going to prepare for the ICD-10?  It is coming soon!!!! 
I look heavenward, eyebrows frozen in an arch. Nod.

Thinking me not taking this seriously enough, she rants on.
If we don't code properly they will reject our claims. And some codes will be paid at a higher fee schedule, some lower. We have to know!!! I'm getting emails about this from every insurance company under the sun! And I'm making a wedding! I have NO time for this!!!!
Send me the links, all I can offer, mustering an ounce, no more, of compassion.

See friends, it can't be that hard. It really can't, and it isn't. It is far harder for medical providers who have to code that it is the left shoulder, not the right, the right kidney, not the left.

But we will have to  learn all new codes, all of us. The old ones are defunct as of October 1; why, no one knows. And, from what my buddy tells me, procedure codes will pack more meaning.

So because I do have the time, I take twenty minutes and log onto a workshop from Optum, a United Behavioral Health (United Health Care) insurance product that I don't accept, but once did, many years ago when getting on the lists of behavioral and mental health managed care products seemed like a good idea. (Just try to get off. It will take you years, but do it. Don't work twice as hard, twice as long, for even less money.)

Here's what the good people at Optum don't say. They don't tell you what codes to use to get paid more, naturally, because a managed care company is not interested in you making more money. If anything, when you call a managed care Provider Relations Specialist, you might be counseled to code down. That way you, the person seeing the vulnerable patient, will be paid less. The managed care company keeps the money. Hello.
Note: no Aspergers in DSM-5

The mellifluous, compassionate presenter makes the whole experience go down easy, puts the care into managed care. As if you need that. Here's what she does say, notes from the slides.

1.         Coding the diagnoses: Read your DSM 5!

All of the new codes are right there, in a white rectangular box with the old codes. Below the words, Autism Spectrum Disorder, in the picture above, you'll find 299.00, the old ICD-9 diagnosis. And next to that, F84.0, the ICD-10 dx.

For patient visits on or after October 1, 2015, code with the ICD 10, in this case, use F84.0. Not before.  For visits in September, or for back visits in 2015, use ICD-9 codes. 

Never use both codes. 

Oh!  And there are even newer codes, code changes since the publication of the DSM 5. Go to   and scroll down to Updated Disorders.  

We will still need to code for medical, psychosocial, and functional levels and prognosis.

In case you haven't really read your DSM 5, you can just skip to page 839, the appendix mentioned above, for a quick and dirty translation of codes from ICD 9 to ICD 10. Except for the changes we just mentioned above.

2.         There is something new to be concerned about on claim forms.

Whether you code by paper or online, electronically, you'll have to indicate if it is an ICD 9 or 10 diagnosis/procedure. 

For paper claims, in box 21, at the top of the box, all the way to the right is a space. Your billing program is already filling that with a '9,' probably.  You want to make sure, for visits on or after October 1, 2015, that it changes that '9' to a '0.' White it out and change it if your program fails you.

Electronic billing will offer choices with radio button, a lot more fun.

To add to the fun, there is an industry standard with electronic claims (form 837). For ICD-9 it looked like this: BK= ICD-9.  Now it will look like this: ABK = ICD 10  No one seems to have any idea what this is all about. Before Kugle? After Baking Kugle? No one knows.

3.         Authorizations, eligibility and benefits

The drill is the same. If you're paid as a managed care provider you will be calling for authorizations, etc., when you see new patients. You don't have to call to reauthorize care for patients who have already been authorized. Remember, however, that I sat through an Optum workshop, and other managed care groups may differ. Best, in my humble opinion, is to get out of network and not have to care. But we all start somewhere.

4.       Specifiers
I indicated above that you will have to specify specifiers, but I'm still not quite sure how. In the DSM-5, however, there are particular codes that you will be adding to your codes, just to keep it all simple. For example, if a patient has been depressed for ten days, not two weeks, check, other specified. If he's been down for two-weeks, then specified.  So clear.

5.      Autism/Aspergers
Aspergers is no longer a diagnosis. It will be considered High functioning autism. All those tee shirts, gone to waste. 

6.      HIPAA 5010

Since 2012, if you're good with HIPAA, you're probably still good. As for me, it is time for another workshop. BCBS, I'm told, has a really good one.

7.  Wrap Up

The Optum workshop kindly provided another link for more information, which we all will surely need, the APA Understanding ICD-10-CM and DSM-5-A Quick Guide.  In straight, easy English, it is a delight, worth a read. 

Remember. . . Time's running out.

But don't panic. You can do this. Even if you are planning a wedding.


Friday, September 04, 2015

Snapshots: Mostly Jewish

We're not likely to get that short
(1)    Looking up  

The other day we were standing in stocking feet and I asked FD, “Am I getting shorter?  And what happens when do you get shorter? Do you lose weight?”

He faced me and said, with certainty, his head inches from mine,
“Yes, you are getting shorter. We all get shorter.” 
He didn’t respond to the weight question.

And I noticed, as he said this, that he had lost some height, and that my chin didn’t point up as high as usual as we spoke, and our eyes weren’t level, but they were almost level.

It was alarmingly intimate.

(2)   Holidays and guilt  
FD waking me up with the shofar

It has happened many times. I’ll be listening to a patient who will suddenly look directly at me, across that perfectly calculated space between us, and declare:
“It’s Catholic guilt. The problem is Catholic guilt.”
There will be a pregnant pause, then a bold continuation:
“You Jews have it too, I think. The guilt.” 
And I confirm this. It is true, for many of us. Guilt is a code that we live by.*(1)

About this time of year I print up a little piece of paper and hand it out at the end of visits.

Here's a list of dates for Jewish holidays coming up. I won't be working or returning calls on these days,*(2) but will get back to you asap. Understand it could be a few days before you get a return call..
Think of this as a yoga retreat for me, out in a desert, far away, but intermittently hopping on a plane, a proverbially late plane, and coming home to work between asanas.
Use the emergency contact if necessary.
Okay, I left out the line about the yoga retreat and the asanas.
Just some of the Jewish holidays

The retreat for Jews, those who sign up, begins in the first Hebrew month of the lunar year, Tishre (rhymes with wish-day). Rosh Hashana. The holiday will be here with the setting of the sun on September 13, a two-day affair, cuz we're Jews.

Then, ten days later, it will be Yom Kippur (the Day of Atonement/Judgement), then Succot (why not build a new home in the backyard) four days after that, culminating with a wild celebration (for the most part alcohol free) Hoshana RabaSimchat Torah, not shown on the calendar above. It goes on and on, or certainly feels that way, and can be quite serious, sobering, which is why many observant Jewish doctors are nowhere to be found on the holidays, except for FD. They seem to find him. 

Even as he's being paged, we're like kids on Christmas, on our best behavior, worried about the King's decisions for our future, no idea how it will all turn out.

What's interesting to me is that there's real anticipatory anxiety going on. Heavenward attention (fear) starts well before Tishre, the month of judgement. Even in the last month of the year, the one we're finishing up just now, Elul, we think that God is listening, a little closer, like at weddings (She attends! Go ahead, ask for it!). The sound of the shofar, the ram's horn, is heard at daily morning services in Elul, loud, insistent, sometimes whiney--plaintive, a plea for mercy. Or a plea for return. Or both.

Some people begin to get nervous mid-July, even before Elul, in the month of Av. As soon as the summer heats up they start examining how they are living their lives and what they should be doing better, differently. It can put a damper on your summer, honestly, examining your deficits.

Emotions are a roller coaster until court is adjourned late in the evening on Yom Kippur, ten days after Rosh Hashana (although the gates remain open, really, until the end of Simchas Torah, and naturally, we're judged every day, in the moment, not for the past so much, as a general rule). But on Yom Kippur the future of every city, tree, insect, person, animal, turtle, lizard, flower, giraffe, and fish is determined. The fast greases a positive verdict.

We'll say, if someone dies just before the new year,
God of mercy, the Old Mighty gave her the whole year
Or when something tragic happens, any time of the year
 It was decided on Yom Kippur
This is an answer, see, to the big question of Jewish guilt, and even the big Why questions. The answer might come down to (1) not praying hard enough, (2) withholding charity, and (3) not making it happen, that promise the year before to very specifically change our behavior, or worse, having no intention to do so. Everybody has to chip in, the stakes for the entire world ride on it.

So you get it, Jewish guilt.  I have no idea what subscribers to other religions have to complain about.*(2)

(3)     Yahrtzeit  

Holidays aren't the only annual interventions. 

When the anniversary of a death is anticipated, families have different ways of handling what can be a healing, if emotional experience.

Some make calls, check out feelings of sadness, empathize and commiserate. There are plans to meet at the cemetery, drop off a flower, or share memories on WhatsApp or a private Facebook group page (others are very public about it). Or there's a picnic. I had a photo shrine pic ready for a previous draft of this post but took it down because FD said Internet stalkers might bother my mother in Heaven. My cousin has pictures of her mom all over her apartment. Sometimes I wonder if our fathers are jealous.

We go to the effort of socializing on or around an anniversary, because we remember, or maybe we forget, but want to connect with other people who remember. Or maybe we just like being with others who care, who still grieve a little, that time of year.*(3)

And it has been said in many a doctor's office, a therapist-type doctor, while tracing emotional cycling, that the anniversaries of deaths are associated with a spike in negative emotion, sadness especially, maybe even depression. The change might begin months before the anniversary. I told one friend who gave me plenty of notice about a dinner invitation that I'd need a rain-check, wouldn't be in the mood. Too close to the yahrtzeit.

The yahrtzeit, for Jews, marks the day a parent, child, or sibling died. We might keep a yahrtzeit for grandparents or aunts and uncles, or other special people, too, but it isn't technically ours. Again, the date of the anniversary is as it lands on the lunar calendar, which varies year to year on the Gregorian calendar (the one most of us keep, January, Feb, etc.) It can be confusing because even Jewish types don't use the lunar calendar much, except to check on the proper time to light the Sabbath and holiday candles.

So we're never really sure when the yahrtzeit will be unless we check that or use a phone app. Or we can wait for a postcard from the synagogue,
Remember so and so, whose yahrtzeit is on such and such a day 
 Most are not so crass to ask for the check, but it might be implied. It is also an invitation, really, to stop by to say kaddish, the special remembrance prayer.

But for many of us, knowing when it will be is too important to wait for the shul's notice. When one of us figures out the date we'll inform the rest of the family.
September 3 is Mom's yahrtzeit; let's do dinner that week.
Or maybe we'll get more specific,
This year, mom's yahrtzeit, the 19th of Elul, will be on Thursday, September 3
Figuring out when will it be can trigger strong emotion, that's the beginning of the anticipatory anxiety I'm talking about. Maybe our brains are reenacting the stressful times attached to the death itself, or the anticipation of the death itself. I randomly remembered, two days after a yahrtzeit, when someone mentioned going to the ER at St. Francis, how I threw myself on my mother, as the paramedics hauled her in on a gurney at the beginning of what was to be the end and said, in answer to her question, "You're not going to die."

So the yahrtzeit is grief work, reliving a trauma, and the experience feels a little like acute stress disorder.

It all makes sense when we're in the moment, when someone is dying, when a death is imminent, inevitable, and comes to pass. Elisabeth Kubler Ross famously noted five stages of grieving: denial, anger, bargaining, depression, and acceptance. For that emotional resolution to continue annually, however, years after someone's passing, tells us everything about how we're made. *(4)
We might forget where we put our keys, may have no idea what we're looking for when we walk into a room, cannot remember who we saw yesterday, but we're wired to remember the important things.*(5)

*(1) If you are too young to know the Crosby Stills and Nash song, Teach Your Children Well, here's a link.

*(2)  Probably all religious codes are the same, capitalize on fear, assuming that within that code is tucked the concept of divine retribution. That tickles our most primal fear, the fear of annihilation.

Which Darwinists believe is burned into our DNA, and mental health professionals insist is a product of parental behavior (the rod), instruction (talks at night before bed, rewarded with hot milk and cookies), and institutional hypnosis (Hebrew school).

Jung's concept of a collective memory explains why all of us, at certain times of the year, are programmed to feel certain ways. Americans just feel like lighting up the barbecue on July 4th to make fireworks with that lighter fluid, consciously or subconsciously looking skyward for the rockets red glare, ala 1776. Groups remember even ancient history, like the Jews remember God holding a mountain over our heads, making us an offer (the Torah) that we can't refuse. Memories are passed on in some still inexplicable way. Gotta love Jung for this one.

Therapists might say that the emotional programming of the Jewish high holidays is necessary because most of the year we're sleepwalking.

And there's this comforting feeling, too, when the season fades away,when everyone anticipates getting back to work without interruption the second week in October this year. We turn, not only to friends and family, but to our Maker, and say,
Same time next year 
 We hope in Jerusalem, if at all possible.

*(3) The crazy thing, should you do this, pass along the memories with one another, discuss feelings about the relationship you had with a person long gone, is that it affords an opportunity to work out some guilt, or neurotic misgivings, legitimate regrets, too, even anger. My brother, at dinner on Sunday, told me that he felt guilty for one thing only, not taking Mom out to dinner more often. And I told him, that after two years, I'm working through some of mine for not confiding more, not telling her the things that might have made us closer, and not listening to her often enough, because I knew she always craved more intimacy with me. If you don't do this, don't have the dinner, don't do anything that brings a loved one to life once again, it is your own loss, imho, and experience.

*(4) I'm told it improves as the years roll on, the intensity of grief work. That's what I tell people.

*(5) The important things, unfortunately, would include traumas, and for that, everyone needs therapy. For the things parents teach us, the things that stick, no matter how many days pass, we might need therapy, too.