This article is intended to share my hard lessons learned, getting myself and the behavioral health agency I head, ready for a major upcoming change.
On October 1, 2015, the US healthcare industry will undergo one of the most significant, broad-sweeping changes of the past decade. The coding system (International Classification of Disease – ICD) used to record diagnoses will change, from version 9 to version 10. This change is far more significant than going from Windows 6 to Windows 7. It’s a bit more like going from a paper chart to an electronic medical record – everything is going to be affected and changed.
As of October 1, all claims for medical services will have to be billed with the new ICD-10 codes, or be rejected. (If you visit the CMS site on the ICD-10 transition, there's scary-looking countdown clock, guaranteed to trigger your anxiety...) The US healthcare system has been on ICD-9 for nearly 30 years now, and this change is going to be a sweeping, tremendously impactful process. Unfortunately, in my experience thus far, most organizations are not approaching the nuts and bolts of this change in an effective way. We are all getting regular emails an letters about this change – unfortunately, most of this information is not directed at behavioral health providers, or our unique needs.
First, in behavioral health, it’s important to recognize that DSM and ICD are two different, but overlapping things. The DSM is a compendium of clinical syndromes and diagnostic labels. The DSM contains codes (alphanumeric codes) in the text, but these codes are not actually DSM codes, but ICD codes that are included in the DSM text to facilitate billing for services. When a behavioral health provider bills for services, the claim includes the ICD code for the mental health diagnosis they are treating. Allen Frances, fellow PT blogger has suggested that we could get along without the DSM. That’s an interesting suggestion, but unfortunately, for many of us, state and managed care bureaucracies around authorization and regulation of services, rely upon or even demand use of the DSM.
In 2013, the APA updated the DSM to version 5. DSM-5 includes both ICD-9 and -10 codes. Unfortunately, throughout the United States, many providers have not fully implemented the DSM-5, because many state systems had embedded DSM-IV strategies in behavioral health structures such as SED/SMI classifications, regulations and policy, etc. In many cases, providers were told to wait to change to DSM-5 until the ICD-10 transition occurred. The ICD-10 transition was originally scheduled for 2014, but was delayed by the US Senate in response to concerns that our healthcare system and hospitals weren’t ready.
Now, many behavioral health providers are preparing to transition to DSM-5 at the same time as they implement ICD-10. In theory, and in the eyes of many practitioners, this shouldn’t be that big a change. It is a huge, dramatic change for medical providers, as the level of specificity required in ICD-10 is far greater than used previously. Unfortunately, for behavioral health practitioners, this change promises to impact their practice and business in important ways, which few are considering. Some of these changes relate to the change to DSM-5, while other changes relate to the impact of ICD-10. Unfortunately, because many people are confused about the differences and overlap between these two things, they’re often approaching these issues ineffectively.
Here are a few of the main areas of preparation and action, which providers need to be addressing in their planning:
Documentation: DSM-IV language has become embedded throughout the documentation related to BH services. Digging out and changing these documents becomes an Easter Egg Hunt From Hell. We commonly use DSM-IV language in clinical documents ranging from psychosocial assessments to progress notes, but DSM-IV terms and processes (such as referring to things like diagnostic Axes) are also included in marketing materials (describing programs as “Substance Abuse/dependency programs”), in incident reports, policies, procedures, claims forms, and a host of other documentation related to service delivery. All of these documents will eventually need to be updated, some sooner than later.
As you approach this updating of documentation, you’ll need to consider some of the things that were required in DSM-IV diagnostic recording, which go away when you transition to DSM-5. For instance, under DSM-IV, we often recorded serious medical conditions or impactful psychosocial factors on Axis 3 or 4. Under DSM-5, there is a “single line” strategy of recording all appropriate diagnoses. Only those medical conditions or psychosocial issues impacting mental health symptoms are really recorded, and there’s not really a “prompt” to record them. I’m concerned that without thinking about these things, many clinicians will lose these issues in their diagnostic and clinical documentation. I’m encouraging clinicians I work with to construct their diagnostic documentary strategy, so that it prompts them to address any comorbid medical issues, and to note any significant psychosocial factors (such as parental separation, job problems, or legal issues). This will help clinicians to attend to these issues, and stay on the right side of auditors and reviewers, who need to see us noting these issues.
Updating Diagnoses: Whether you are already using DSM-5 or not, you are going to have to record and/or render a new diagnosis for ICD-10. In many cases, this is not a simple one-for-one process. Beware of crosswalks. Some systems are promoting the use of paper or automated crosswalks that tell you what the ICD-10 diagnosis code is for an ICD-9 diagnosis. I’m very leery of these. First, you’re relying on this thing to tell you what the proper diagnosis is, and frankly, errors in them have already been found. Secondly, numerous ICD-9 and/or DSM-IV diagnoses don’t directly translate to only one ICD-10 code. ICD-10 is more specific, and in many cases, going from ICD-9 to 10 requires a clinician choose between several diagnostic options. Ethically, that decision is one which must be made by a licensed clinician. It IS the rendering of a new diagnosis.
Process: How does that new diagnosis code get entered into a provider’s system, whether it’s a paper chart or an electronic one? Not enough people are paying attention to this critical piece in my opinion, and this issue is a work-intensive one. It’s critical in order to get paid, that starting October 1 (or before) clinicians obtain and record a new diagnosis code. But someone, whether it’s the clinician themselves, or a clerk, is going to have to enter that new code, for every single patient, into the systems used to submit claims. In many cases, of group practices or agencies, this is going to require overtime, and maybe even hiring temporary help, in order to update all of this information. Further, what happens to the old ICD-9 code? If you delete it or overwrite it, you might regret this, as that code will be needed for any processing or adjustment of claims for services prior to October 1.
Patient education: Clinicians have to be prepared to educate their patients about the need for this change, and what it means. In some cases, it may be a significant change. A person diagnosed with Aspergers’ Disorder under DSM-IV has a new, different diagnosis under DSM-5. When a new diagnostic evaluation is needed, in order to obtain this new ICD-10 diagnosis code, how is the need for that evaluation explained to the patient? I believe this is an opportunity for clinicians to educate patients about their diagnoses, and what they mean, and also to review clinical progress and identify any current symptoms which might not have been previously addressed. Under both DSM-5 and ICD-10, the old “not otherwise specified” diagnoses are minimized, and discouraged, for good reason. Clinicians using “unspecified” codes need to be aware that their practices and records could come under increased scrutiny in the future, as the healthcare system drives towards greater detail and specificity in services and diagnoses.
Stakeholder education: One of the things I’ve learned in this process is how many external stakeholders use and rely upon our clinical diagnoses. Certain diagnoses are approved for payment by systems such as Medicaid and Medicare, whereas others are not. As diagnoses change, there may be impact upon eligibility for services or benefits such as Social Security. Diagnoses changes have an impact on legal status at times, and probation/parole officers often need to understand what it means when peoples’ diagnoses change. Many systems relied upon the GAF, though we all wished they wouldn’t Now that it is gone, there’s not a clear or recommended replacement (WHODAS is suggested in the DSM-5, but few states are adopting it thus far…)
Claims Monitoring: If you as a clinician are submitting claims for reimbursement to third-party payors, the ICD-10 transition has the potential to have a huge impact on your monthly receivables. Some sources are recommending that providers should have 90 days cash on hand, to cover expected delays in payment. While the overall impact of ICD-10 transition on behavioral health claims may be light, especially in providers who have already transitioned to DSM-5, the impact on medical systems is going to be huge. And, when those medical claims start to fail, medical providers are going to be howling for help and support. Little old behavioral health providers should expect that their needs may go ignored for a while, as large payor systems work to prioritize large medical providers. Regardless, well before October 1, providers need to have verified that their entire payment system has been tested for ICD-10 readiness. If you use an EMR or an electronic claims clearinghouse, it is critical that you verify that each piece of this system is ready and able to start using ICD-10 codes as of October 1.
Vacation plans in October? Yeah, you should cancel those. If your business lives off of reimbursements for service claims, you should expect to spend most of October biting your fingernails and hoping that both your systems and those of managed care organizations, have been changed, updated and matched-up in the right ways, to allow the moneys you are owed for services, to get processed.
Many behavioral health providers don’t bill insurances or submit claims. They ask for cash payment from those they serve. I understand this reluctance to deal with the complexity and inefficiency of managed care and governmental bureaucracies. Unfortunately, this limits effective behavioral health services to those who can afford to pay cash. I fundamentally disagree with this. Further, it overburdens the publicly-supported system that is serving the behavioral health needs of the rest of society. Those agencies and providers, already stretched thin, now stand to face even greater burdens under this upcoming transition.
Sadly, this isn’t the last of the changes. We can expect ICD-11 as soon as 2017. Regular updates to DSM-5 have been predicted as well. So, don’t shred the action plans you develop to get through this process. You will need them again soon.