Transcript W15_Daubert_ICD

ICD-10-CM Psychological and Behavioral Disorders
Regulatory Requirements and
Relationship to Clinical Use of DSM-5 Diagnostic Criteria
Scott D. Daubert, Ph.D.
VP, Operations
Agenda
• Overview, introduction and history of ICD-10.
• The ICD-10-CM.
• Differences between ICD-9-CM and ICD-10-CM structures.
• Framework of the ICD-10-CM.
• Clinical descriptions and diagnostic guidelines:
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DSM-IV-TR and DSM-5.
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WHO guidelines.
• Preview of ICD-11.
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ICD-9 History and Overview
• The World Health Organization (WHO) developed ICD-9
for use worldwide:
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Global, cooperative statistical effort to report and improve public health.
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The U.S. developed “clinical modification” (ICD-9-CM).
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Implemented in 1979 in the U.S.
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Expanded number of diagnosis codes.
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Developed procedure coding system.
• ICD-9-CM diagnoses — used by all types of providers.
• ICD-9-CM procedures — used only by inpatient hospitals.
• Impact for PerformCare is limited to diagnoses.
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ICD-9 History and Overview
• What is ICD-9-CM used for?
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Calculate payment — Medicare Severity-Diagnosis Related Groups (MS-DRGs).
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Adjudicate coverage — Diagnosis codes for all settings.
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Compile statistics — Original reason for WHO global standards.
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Assess quality — Diagnoses is a important component of directing treatment.
• ICD-9-CM is outdated:
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30 years old — Technology has changed.
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Many categories full.
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Not descriptive enough, not intuitive in organization.
• What characteristics are needed in a coding system?
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Flexible enough to quickly incorporate emerging diagnoses and procedures.
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Exact enough to identify diagnoses and procedures precisely.
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ICD-9-CM is neither of these.
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ICD-10 History and Overview
• 1990 — Endorsed by World Health Assembly (diagnosis only).
• 1994 — Release of full ICD-10 by WHO.
• 2002 (October) — ICD-10 published in 42 languages (including
six official WHO languages).
• Implementation:
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138 countries for mortality.
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99 countries for morbidity.
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January 1, 1999 — U.S. implemented for mortality (death certificates).
• 95% of the world’s health professionals already use ICD-10.
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Countries Using ICD-10 For Reimbursement or Case Mix
• United Kingdom (1995)
• Nordic countries (Denmark, Finland, Iceland, Norway, Sweden)
(1994 – 1997)
• France (1997)
• Australia (1998)
• Belgium (1999)
• Germany (2000)
• Canada (2001)
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Structural Differences — ICD-9-CM Diagnoses
• ICD-9-CM has three to five digits.
• Chapters 1 – 17: All characters are numeric.
• Supplemental chapters: First digit is alpha (E or V), remainder are
numeric.
• Examples:
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311 — Depressive disorder not elsewhere classified.
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296.32 — Major depressive affective disorder recurrent episode
moderate degree.
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V61.20 — Counseling for parent-child problem unspecified.
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Structural Differences ICD-10-CM Diagnoses
• ICD-10-CM has three to seven digits:
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Digit 1 is alpha (A – Z, not case sensitive).
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Digit 2 is numeric.
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Digit 3 is alpha (not case sensitive) or numeric.
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Digits 4 – 7 are alpha (not case sensitive) or numeric.
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If there is a decimal, it is always after the 3rd character.
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ICD-9-CM has 14,025 codes, while ICD-10-CM has 68,069 codes.
• Examples:
2014 ICD-10-CM Code
F70
F31.2
F20.0
2014 ICD-10-CM Description
Mild intellectual disabilities.
Bipolar disorder, current episode manic
severe with psychotic features.
Paranoid schizophrenia.
DSM-5 Description
Intellectual disability (intellectual
developmental disorder), mild.
Bipolar I disorder, current or most recent
episode manic, with psychotic features.
ICD-9-CM Code
319
296.44
295.30
F20.9
Schizophrenia, unspecified.
Schizophrenia.
F11.221
Opioid dependence with intoxication
delirium.
Opioid Intoxication delirium, with moderate or
severe use disorder.
295.90
292.81
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Framework of the ICD-10-CM
• 21 chapters in the list of diseases and injuries:
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Chapter 1 — Certain infectious and parasitic diseases (A00 ‒ B99).
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Chapter 2 — Neoplasms (C00 ‒ D49).
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Chapter 3 — Disease of the blood and blood-forming organs and certain
disorders involving the immune mechanism (D50 ‒ D89).
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Chapter 4 — Endocrine, nutritional and metabolic diseases (E00 ‒ E89).
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Chapter 5 — Mental, behavioral and neurodevelopmental disorders (F01 – F99).
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Continues to Chapter 21…
• All of the mental and behavioral disorder codes begin
with the letter F.
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Although there is room for up to seven characters, most of the BH disorders
have four or five total characters.
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Pause for Questions
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Framework within Chapter 5, Behavioral Health, F codes
ICD-10-CM Code Range
Description
F01 ‒ F09
Mental disorders due to known physiological conditions.
F10 ‒ F19
Mental and behavioral disorders due to psychoactive
substance abuse.
F20 ‒ F29
Schizophrenia, schizotypal, delusional, and other non-mood
psychotic disorders.
F30 ‒ F39
Mood (affective) disorders.
F40 ‒ F48
Anxiety, dissociative, stress-related, somatoform, and other
non-psychotic mental disorders.
F50 ‒ F59
Behavioral syndromes associated with physiological disturbances
and physical factors.
F60 ‒ F69
Disorders of adult personality and behavior.
F70 ‒ F79
Intellectual disabilities.
F80 ‒ F89
Pervasive and specific developmental disabilities.
F90 ‒ F98
Behavioral and emotional disorders with onset usually occurring
in childhood or adolescence.
F99
Unspecified mental disorder.
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Clinical Descriptions and Diagnostic Guidelines (DSM-IV and DSM-5)
• As of Oct. 1, 2014, the ICD-10-CM code set is the HIPAA-adopted
standard, and required for reporting diagnosis for dates of service
on or after Oct. 1, 2014. (Delayed again until Oct. 1, 2015.)
• Neither the DSM-IV nor DSM-5 is a HIPAA-adopted code set, and
may not be used in HIPAA standard transactions (e.g., claims).
• DSM-5 is “compatible” with both ICD-9-CM and ICD-10-CM.
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The DSM-5 manual provides a crosswalk to both sets of codes.
• There is no published (APA) DSM-IV direct crosswalk to
ICD-10-CM.
• The Oct. 1, 2015, date does not mandate clinical use, but such
use must be translated to ICD-10-CM as of that date.
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An Example of a Crosswalk Discrepancy
A case of agoraphobia with panic disorder:
• DSM-5 diagnosis of agoraphobia.
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ICD-10-CM crosswalk = F40.00, Agoraphobia, unspecified.
• DSM-5 diagnosis of panic disorder.
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ICD-10-CM crosswalk = F41.0, Panic disorder [episodic paroxysmal anxiety]
without agoraphobia.
• There is no DSM-5 category that combines agoraphobia with
panic disorder.
• In ICD-10-CM, F40.01 = Agoraphobia with panic disorder.
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ICD-11 and the WHO CDDG
• Clinicians need guidance for making diagnoses beyond
just having a code set.
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This has been the role of the DSM publications, but only in the United States.
• The Blue Book, published by the WHO (1992):
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The ICD-10 Classification of Mental and Behavioral Disorders: Clinical
Descriptions and Diagnostic Guidelines (CDDG).
Explicitly removed from use in the United States.
Not part of ICD-10-CM.
http://www.who.int/classifications/icd/en/bluebook.pdf.
The CDDG is being updated for ICD-11.
WHO adoption of ICD-11 is scheduled for 2015.
• WHO opinion of DSM-5:
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The definition of disease “cannot be legitimately managed by a single
professional organization representing a single health discipline in a single
country with a substantial commercial investment in its products.”
Goodheart, Carol D. (2014) A Primer for ICD-10-CM Users.
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Summary
• Dates of service on or after October 1, 2015.
• F Codes = Behavioral health.
• Further subdivision of F Codes 01 ‒ 99.
• Minor incompatibilities between DSM-5 and ICD-10-CM.
• Many more diagnostic options in ICD-10-CM.
• Not all DSM-5 diagnoses are F category, or behavioral health.
• PerformCare next steps:
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Issuance of provider notice and crosswalk.
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IS system upgrades.
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Testing with trading partners.
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Web Resources
CMS:
• General ICD-10 information (including regulations)
http://www.cms.hhs.gov/ICD10.
CDC:
• General ICD-10 information and mapping
http://www.cdc.gov/nchs/icd/icd10cm.htm.
DPW:
• General ICD-10 information and FFS implementation
http://www.dpw.state.pa.us/provider/icd10information/index.htm.
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Questions?
Contact presenter with additional questions:
Scott Daubert, Ph.D.
VP, Operations
PerformCare
[email protected]
717-671-6535
www.performcare.org
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