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NEW CODING RULES FOR ADDICTIONS: THE ICD-‐10/DSM-‐5 AND PROTECTING YOUR ORGANIZATION THROUGH TRANSITION Prepared exclusively for: MAARCH 2014 Annual Conference, St. Paul, MN Behavioral Health Solu/ons, P.A. LiseQe Wright, ExecuTve Director Procen/ve Pat Stream, Customer Success Manager October 29, 2014
Agenda • IntroducTon to the ICD System • Understanding ICD/DSM ApplicaTons • Coding and DocumentaTon ImplicaTons • ICD-‐10 OrganizaTonal Readiness: Business Process and Systems Inventory • Payers and TesTng Processes • Risk MiTgaTon Strategies • Staff Training Needs
• 1990 World Health OrganizaTon (WHO): “is the standard diagnos.c tool for epidemiology, health management and clinical purposes. This includes the analysis of the general health situa.on of popula.on groups. It is used to monitor the incidence and prevalence of diseases and other health problems.” • Massive change from the ICD-‐9 to ICD-‐10 • Increased specificity: New medical condiTons, treatments, and devices • Naming and Coding System that is more accurate
PosiTve Features of the ICD-‐10 • More Substance Use codes • BeQer descripTons of condiTons • Enables us to document more accurately, conTnuity of care • Will allow for geneTc condiTons and other applicable condiTons to our work • Helps us understand the encounter beQer, i.e.: iniTal, subsequent or sequelae (late effects)
• StandardizaTon, research and development, staTsTcs • BeQer for IntegraTve care models, co-‐occurring condiTons
• ICD-‐10/DSM-‐5 • Not aligned • Discrepancies with: • Numbers of diagnoses • Language • DocumentaTon • Payer Requirements • DiagnosTc Criteria WriQen Policy and Procedure’s will need to be updated as a result
• Chapter “F” = Chapter 5 in ICD-‐10 • “10” Category = drug of choice or condiTon i.e.: alcohol • Last 4 digits represent the clinical state: eTology, severity, manifestaTon, and placeholders • Note: Some T, Y, N, K, J, R, and other codes are applicable to us and are required for us to document
Expanded Diagnoses Examples in DSM-‐5 and ICD-‐10 • Substance Use codes contain the most expansion • DSM-‐IV-‐TR has 9 diagnoses involving Cannabis • DSM-‐5 has 22 diagnoses involving Cannabis • ICD-‐10 has 44 diagnoses involving Cannabis
• BiPolar ‘s, Schizophrenia/PsychoTc, and Anxiety SecTons are very different between the DSM-‐5 and ICD-‐10 • Many more Major Depressive diagnoses in the ICD-‐10 than in the DSM-‐5
CMS on DSM-‐5 and ICD-‐10 • “In current prac/ce by the mental health field, many clinicians use the DSM-‐IV in diagnosing mental disorders. As of May 19, 2013, the DSM-‐5 was released. Can these clinicians con/nue current prac/ce and use the DSM-‐IV and DSM-‐5 diagnos/c criteria?”
• Yes. The Introductory material to the DSM-‐IV and DSM-‐5 code set indicates that the DSM-‐IV and DSM-‐5 are “ compaTble” with the ICD-‐9-‐CM diagnosis codes. The updated DSM-‐5 codes are cross walked to both ICD-‐9-‐CM and ICD-‐10-‐CM. As of October 1, 2014, the ICD-‐10-‐CM code set is the HIPAA adopted standard and required for reporTng diagnosis for dates of service on and aper October 1, 2014.
• Neither the DSM-‐IV nor DSM-‐5 is a HIPAA adopted code set and may not be used in HIPAA standard transacTons. It is expected that clinicians may con/nue to base their diagnos/c decisions on the DSM-‐IV/DSM-‐5 criteria, and, if so, to crosswalk those decisions to the appropriate ICD-‐9-‐CM and, as of October 1, 2014, ICD-‐10 CM codes. In addi/on, it is s/ll perfectly permissible for providers and others to use the DSM-‐IV and DSM-‐5 codes, descriptors and diagnos/c criteria for other purposes, including medical records, quality assessment, medical review, consulta/on and pa/ent communica/ons.
• Dates when the DSM-‐IV may no longer be used by mental health providers will be determined by the maintainer of the DSM-‐IV/DSM-‐5 code set, the American Psychiatric AssociaTon, hQp://www.dsm5.org
Understanding ICD-‐10 Coding Rules • Foreign to most clinicians • Always been in existence, and BH/SU have goQen off “easy” • HealthCare Reform and HIPAA commands we are more specific • Our job is to know what the rules are, then decide how to proceed
• Most do not have cerTfied coders • There are official guidelines and requirements around what you can document or NOT document when it comes to the ICD-‐10 and DSM-‐5 • Gesng clinicians to ship out of NOS mode will be hard • We can, and should, now document and code for co-‐morbid medical condiTons • Required now to code for IntenTonal Self-‐Harm and/or Self-‐Poisoning
While NOS is even more appealing now, Auditors will be on the look-‐out, and so should you!
Understanding the Official PublicaTons We Will/Should Use Moving Forward 1. DSM-‐5 2. ICD-‐10 CM Codes: • Various sources will have these (EHR, cheat sheets, another lisTng) • ICD-‐10 CM codes are sancToned and governed by the US
3. ICD-‐10 CM Tabular Index (2015 already published) • The document that lists, numerically, all the diagnoses in the ICD-‐10-‐CM • Typically used by Coding offices
4. ICD-‐10-‐CM Official Coding Guidelines (annual): • The rules that tell us exactly how to document to support the diagnosis • Covertly endorsed by APA (p.23 in DSM-‐5)
5. ICD-‐10 ClassificaTon of Mental and Behavioral Disorders: Clinical DescripTons and DiagnosTc Guidelines (aka “Blue Book”)
• Published by: CMS and NaTonal Center for Health StaTsTcs (NCHS) • Approved by: American Hospital AssociaTon, AHIMA, CMS, and NCHS
• “These guidelines are a set of rules that have been developed to accompany and compliment…ICD-‐10-‐CM itself….These guidelines are based on the coding and sequencing….Adherence to these guidelines when assigning ICD-‐10CM diagnosis codes is required under HIPAA.”
Level of Detail in Coding and CharTng • Diagnosis codes are to be used and reported at their highest number of characters available • Example: If a condiTon has 6 digits, then use all 6 digits AND document to account for all 6 aspects of the condiTon
• A three-‐character code is to be used only if it is not further subdivided • Example: Do NOT use just F10. Alcohol ______? What?
• A code is invalid if it has not been coded to the full number of characters required for that code, including the 7th character, if applicable
• DisrupTve Mood DysregulaTon Disorder: not listed in either ICD-‐9 or ICD-‐10
• “Exact” mapping for this DO is not available as a result • Closest applicable ICD-‐10CM code would be: • F34.8: Mood Disorder, Other Specified
q How will your clinicians handle this? q What will the insurer pay for? What’s in your payer contract? q How will this be documented? q Can you standardize documentaTon and how?
Nuances, Timelines, and Confusion • Do not underesTmate the subtle, and overt, differences between the ICD-‐10 and the DSM-‐5 • Know who wants what in terms of clinical documentaTon, diagnoses, and their Tmelines • UTlizaTon of 3 possible code-‐sets at any given Tme • This will be a major cultural ship in the following processes: • How clinicians diagnose and document • The level of specificity to which clinicians will have to document • Moving away from the NOS categories • Having to flip through the manuals (likely not done in years) • HandwriTng/coder improvements
Crosswalk’s: VarieTes • The APA’s produce their Frequently Used Codes • AMA has “Reference Tables” • OrganizaTons can produce their own • CMS/CDC produces GEMS: General Equivalent Mappings: A “sort-‐of” code-‐to-‐code translaTon (no direct path/crosswalk) Ø 18% of codes have mulTple choices in the other code set!
KEEP IN MIND: NO ONE TO ONE CODE MATCH IS POSSIBLE SO CLINICAL JUDGEMENT, SPECIFICITY, AND DOCUMENTATION ARE CRITICAL!
Every system that holds, transmits, or analyzes health data will need to be modified
• CMS on TesTng: “Tes.ng will ensure ICD-‐10 compliance across internal policies, processes, and systems, as well as external trading partners and vendors”
• Without thorough internal and external tesTng, you will have no idea if you will be ready or what will happen to your revenue income aper October 1, 2015
• Two Key Factors: • a) Can you connect AND exchange ICD-‐10 informaTon? • b) Can the payer handle, adjudicate, and process the claim correctly?
Document to SubstanTate Diagnosis • All the KEY medical concepts, relevant to care now and looking to the future • ICD-‐9: Code and DescripTon: 292.85 Drug induced sleep disorders • ICD-‐10: Code and DescripTon : F13.282 Seda.ve, hypno.c or anxioly.c dependence with seda.ve, hypno.c or anxioly.c-‐induced sleep disorder
• You would then write in your record: “A paTent is evaluated for a [drug induced] [sleeping disorder] that is related to [dependence] on a [sedaTve drug].”
Role-‐Based Training Ø Clinical staff will need to understand not just diagnoses, but also medical necessity & increased specificity in clinical documentaTon expectaTons (MD’s: E & M improvements for Medical Decision Making/LOC); DSM-‐ICD relaTonship
Ø Billing will need to understand coding, crosswalks, when to punt back to clinical
Ø Any intake/pre-‐registraTon staff will need to know basic diagnosTc groups
Ø Compliance: understand reporTng, data collecTon, clinical documentaTon guidelines, adherence, etc.
AddiTonal Resources Note that the majority of ICD-‐10 resources are geared towards the medical industry, who is transiToning from ICD-‐9 to ICD-‐10.
Some these resources do not take into account the DSM:
• CMS: www.cms.gov/Medicare/Coding/ICD10 • AMA: Express Reference Cards for BH
• The Clinicians Toolbox: hQp://theclinicianstoolbox.com (ICD-‐10 for BH/SU codes ONLY, produced by a clinician, $27)