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.



Travis Dailey said...

Hi therapydoc,

Thorough break down of ICD 10 codes and perfect timing. Enjoy your conversational writing. Definitely will be spreading this post around. ;)


Sara said...

This is great. So many of my clients are absolutely petrified of this change, when they really do not need to be. I appreciate you breaking it all down in such a succinct manner. I'll be referring many people this way.

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