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  

Borderline Personality Disorder and the DSM

Almost 30 years ago, when I started my master's degree program, if we discussed borderline, that meant we were discussing psychosis. A "borderline" was a person on the "border" of psychosis.

In those days we were taught that psychopathology either manifested as

(1) a neurotic disorder, people were depressed or they worried endlessly over problems stemming from unresolved childhood guilt; we called them the Woody Allens;

(2) a psychotic disorder, accompanied with hallucinations and/or delusions; the patient being out of touch "times three," meaning he didn't know his name (person), where he lived (place) or the day of the week (time) ;

or

(3) a borderline disorder, essentially No-Man's Land, neither neurotic or psychotic, but definitely leaning towards the latter.

Borderline meant having such poor boundaries that the patient felt blended with others psychologically, did not see where his or her perception of others' thoughts or intentions could be wrong. The condition would manifest as severe abandonment anxiety, anger or depression, and certainly suicidality, ala that movie, Girl Interrupted. Perhaps the behavior was manipulative, but who knew for sure?

Disturbed, that we recognized. Depression didn't have to enter the equation (but it usually did).

Merging was thought the natural consequence of not having separated properly from parents, not having individuated or developed into an independent person, secure all on one's own. And to individuate well, one needed psychologically healthy parents who encouraged that differentiation and confidence.

You see why I push it, some thirty years later.

The first Diagnostic Statistical Manual (DSM, 1952), the Big Book of psychiatric diagnosis, included an etiological component that subsequent versions for the most part phased out in favor of statistics. Empirically-based medicine had evolved.

But ideas of merging and family dysfunction had a place in the first manual, as did other etiological explanations of pathology, such as the stress of combat contributing to substance abuse in the military. Not surprisingly, the American Psychiatric Association (APA) released the first DSM to meet the needs of the military— soldiers had returned from war alcoholic and traumatized.

This was also about the time that psychiatrists recognized the association between self-medicating with alcohol, and the manic component of bi-polar disorder.

The need to mesh psychiatric diagnosis with numeric coding consistent with the International Statistical Classification of Diseases and Related Health Problems [(ICD), the World Health Organization] followed soon thereafter. Then the mission of the DSM officially shifted from the explanation of psychiatric disorders to descriptions.

And as clusters of features and symptoms emerged for each new edition, psychological disorders became medical disorders, handily recognizable sets of features and symptomatology.

Our latest edition, the DSM IV-TR has refined the process, adding cultural diversity to the mix and some general psycho-social history that is associated with certain disorders. There is also an occasional reference to how genetics steer the course for others.

But to diagnose, we focus upon what we see and hear in our offices.

And borderline no longer necessarily implies having "poor boundaries." The disorder is now neatly cataloged as an Axis II personality disorder with easy to recognize socially dysfunctional features (see below). But those of us who remember what it means to people to feel less than whole, to have a need to own or merge with someone else's ego, body, or personality, are more likely to empathize with that particular pain, even though it isn't on the list.

Lucky for us, the DSM modifies, adds, and removes diagnoses with each edition.* So I look forward to seeing what the next one (2012) will do with borderline.

As it stands, anyone with or without a college vocabulary can take a stab at reading and understanding the DSM IV-TR to diagnose family and friends. Anyone can look up a diagnosis like "Borderline Personality Disorder," find the features, and label others. I started this post because a patient wanted me to list the features so that she could do that. You, too, might become rather good at psychiatric diagnosis with a working knowledge of the DSM IV-TR, assuming memory and retention serve.

It is a free country. Go buy a copy. (But pop for the full edition if you do, not the condensed spiral). It will teach you little about how a person develops a disorder or what to do about it, but at least you won't be caught using terms like "split personality" or "multiple personality disorder" anymore.

We'll get to the Dissociative Disorders another day.

But you wanted to know about Borderline Personality Disorder. So here you go. Here's what it says in the book:

Diagnostic criteria for 301.83 Borderline Personality Disorder

A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

(1) frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.

(2) a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization or devaluation

(3) identity disturbance: markedly and persistently unstable self-image or sense of self

(4) impulsivity in at least 2 areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.

(5) recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior

(6) affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days)

(7) chronic feelings of emptiness

(8) inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)

(9) transient, stress-related paranoid ideation or severe dissociative symptoms

Well, on the re-read, perhaps one might need a dictionary, if not a graduate school education, to really get this.

You can see why it's considered a VERY painful condition. Painful to have, painful to treat, painful to live with, all around painful. The disorder always calls me to task, forces my patience, and ultimately brings out my compassion. It's difficult, emotional work and I've heard time and again from peers that working with too many patients suffering from borderline personality disorder contributes significantly to burn-out.

But there are those who burn-out working with people who suffer from depression, too.

Notice my use of language. SUFFER FROM. You'll read on the Web that people think of themselves as borderlines, or bi-polars, obsessive-compulsives, depressives, or schizophrenics.

The better way to refer to someone with a disorder is:

a person who suffers from schizophrenia

or a person suffering from borderline personality disorder.

And so on. We don't say, "She's schizophrenic." Or, "He's bi-polar."

That minimizes a person. The process does that already. We don't need to add to it.

Copyright 2007, therapydoc

*Homosexuality, for example, is no longer considered a disorder, and it is likely that in the fifth edition of the DSM we will see Adult Asperger's and Adult Attention Deficit Disorder, currently two disorders of childhood.