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 Psychiatry.org/dsm5   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.

therapydoc  

Internet Gaming Addictions and the DSM-5

Were it not for my practice, and now, the last section of the remarkable DSM-5, I wouldn't be blogging about this. It feels like such a scrooge-thing to do. A kid finds this awesome present, an X box 360 under the tree, and his mom reads ENT and warns. . .

Enjoy. But remember. It is a starter drug.

Like our first flip phone was a starter drug, too, right?

We can laugh, but couples do present in therapy, meaning they are in therapy because they disagree (fight) about one of them having a compulsion to play games online with friends. He isn't finishing his second shift responsibilities, and worse, isn't coming to bed at night. Every night is Christmas, up late waiting for an online Santa to lose.

Competition rocks, really raises those endorphins.

At the end of the DSM-5, page 795, we find a new disorder proposed for further study. Internet Gaming Disorder. No code yet.

Interestingly, Persistent Complex Bereavement Disorder is among these disorders under consideration. I have seen it in practice, had no proper way to diagnose the syndrome, other than to slap on Major Affective Disorder, Single Episode, Moderate. The patient's depressive episode felt severe, but different. Hopefully there will be a DSM-5 TR (text revised) or a DSM-6 coming up soon that includes Persistent Complex Bereavement Disorder, and provides an actual code, or number.

As you know, proper diagnosis has implications for treatment.

Not to get too distracted, sorry, but Internet Gaming Disorder, is among the conditions that haven't quite made it to prime time, are merely under consideration. But that is a big thing, implies we are certainly within our rights to warn kids, friends, co-workers about devices as starter drugs.

Here are the proposed criteria, paraphrased, for IGD, Internet Gaming Disorder.

Persistent and recurrent use of the Internet to engage in games, often with other players, leading to clinically significant impairment or distress as indicated by five or more of the following within a year:
1.  Preoccupation with online games, even past and upcoming games. Internet gaming is the dominant daily life activity.
2.  Withdrawal when Internet gaming is taken away, meaning irritability, anxiety, or sadness.
3.  Developed Tolerance-, needing to spend increasing amounts of time in play online.
4.  Unsuccessful attempts to control Internet game participation.
5.  Loss of interest in previous hobbies.
6.  Knowing it is creating problems in self and relationships, yet continuing to play excessively.
7. Has deceived others about the amount of time gaming online.
8. Uses Internet gaming to escape a negative mood.
9. Loss of relationships, jobs, or academic opportunity and success, due to Internet gaming.

Note: The above applies to nongambling Internet games, and does not include required professional use and is limited to gaming, not other recreational or social, sexual sites.

We will be asked to specify the severity, mild, moderate, or severe.


I, for one, am grateful that my particular obsession, blogging here, is back. Only yesterday Simon and Schuster sent me a book that is likely to roast everything we therapists do, Promise Land, My Journey Through America's self-help Culture, (note the grammar), written by a woman who has been through many different types of therapy none of them good. and probably is going to tell us that Everyone Does Not Need Therapy. Could be, but it sure feels that way.

I'm looking forward to reading Jessica Lamb-Shapiro's amazing read. The reviews so far are amazing.

Light reading, as opposed to the DSM. And let's talk. Until you've been to six AA meetings and hate them all, can you really say that AA isn't for you? Same thing with therapy.

Six therapydocs and you have the right to complain.

I'll get to it this weekend.

therapydoc

Blogging (Writing) and Reading, Even When You are Grieving

First, I apologize for blogging so rarely the past six months. We say that writing can be therapeutic, but you do need a certain amount of neuro-transmitters, endorphins, serotonin, zipping around upstairs to put out. 

But that's going to change. After all, I've studied the new DSM 5

DSM 5

and there's much to say about diagnosis.


 Yeah, it was expensive.

But mainly because time heals.  I'm beginning to notice things again, like in the old days, when something, any random thing, would happen and I would tell FD: I must blog about this. That's happening again.

The job, when a parent passes away, as any therapist will tell you, is to grieve, but also, to get out there, be in the world .When you're running on empty, that can be hard. So for some of us the best therapy is to sit around and read, preferably in some yoga posture, learn new things. Or listen to the radio, watch TV.

Listening to NPR last week I heard two journalists talking about books that might make nice holiday gifts. Below are a few of my own suggestions. If any of you have others, chime in. They don't have to be all that educational. Nothing too violent, and really, no gratuitous sex. Emphasis on gratuitous.

My thinking, read to yourself or maybe even better, to someone else. A personal favorite, The Ugly Duckling.

If alone, and you're choosing from the the National Public Radio lists, be careful about the late night thrillers.

Where'd You Go, Bernadette?

The books below won't keep you up, guarantee, with the exception perhaps of  
Where'd You Go, Bernadette: A Novel Maria Semple's novel is wonderful, you'll read it in one sitting.

Blind Spot and the Harvard Racism Test

Just in case you don't think you're a racist, think again. This book not only teaches you everything you need to know about improv, but about our unconscious biases. Blind Spot

We've talked about John Elder Robison's book, but if you're new here, check it out. A man realizes he has Asperger's Syndrome and rises to success in spite of it. Asperger's is now officially on the autism spectrum, no longer a disorder unto itself.

Look Me in the Eye

Look me in the eye 

 Mr. Robison's brother, Augusten Burroughs writes about everyone's favorite drug, alcohol in DRY.



 
dry

And because you can never read enough about BPD . . .

Borderline Personality Disorder in Adolescents




A patient just the other day asked me, literally, "Is happiness just a myth?"  I had to flash the book at him and say, "Unfortunately, yes. But it is a nice myth."
 The Myths of Happiness

The Myths of Happiness

Men on Rape 
What you'll find fascinating about this book, and you may only get it used, is the treatment of language, how men talk about women, how they talk to women. Talking tends to be something we don't think about nearly enough.Timothy Beneke's book has been on my shelf for years. I won't lend it out.



Monkey Mind
Daniel Smith's (300.02 DSM-5) struggle with a different disorder, what some of us call screaming anxiety.

That's what it is like to have a Monkey Mind. Not fun.

Language of flowers

 There are so many languages, but until this book, who knew that sending yellow roses means something entirely different than sending red or white roses. This book is worth buying for the glossary alone. It is an amazing story about foster care. As you might suspect, being punted around as a child from one home to another isn't always the best thing for a person. But some survive, and thankfully, they know how to either tell their story, or write about it themselves.

The Language of Flowers

therapydoc