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38100023812500DSM-5 and ICD-10-CMDocumentation and Coding Overview for Behavioral Health ProvidersDSM – 5 BasicsWhat is DSM-5Diagnostic and Statistical Manual of Mental Disorders (“DSM”) is the authoritative guide to the diagnosis of mental disorders.Enables clinicians and researchers from multiple backgrounds and orientations to have a common language to communicate the essential characteristics of mental disorders presented by the individuals who they treat.Intent to provide an objective assessment of symptom presentations in a variety of settings; inpatient, outpatient, consultation-liaison, community based programs, primary care.Serves as tool for collecting and communicating accurate public health statistics on mental disorder morbidity and mortality rates.Serves as a textbook for students and seasoned professionals in understanding and diagnosing mental disorders; those common and rare.History of the DSM-5DSM published by the American Psychiatric Association, first release in 1952 and updated several times since but last revision was the DSM-IV-TR in 2000.DSM-5 released May 2013 (represents 13 years in the making).Classification of disorders largely harmonized with ICD; DSM criteria define disorders with are then identified by ICD diagnostic names and code numbers.In the DSM-5, both ICD-9-CM and ICD-10-CM codes are assigned to a related DSM-5 diagnoses.There are some DSM-5 diagnoses for which there is not a unique ICD code; there is therefore some “doubling up” of DSM-5 diagnoses with ICD-9/ICD-10 codes:EXAMPLE: Hoarding Disorder and Obsessive Compulsive Disorder both share ICD-9/ICD-10 as 300.3/F42 CDI TIP: Practitioner should write out diagnosis for accuracy.Highlighted Changes from DSM-IV to DSM-5Categorical to Dimensional Approach to DiagnosisPrevious versions of the DSM based on a large number of narrow diagnostic categories.It is now recognized that in clinical reality there is a widespread sharing of symptoms and risk factors across many disorders.Shared family traits, genetic risk factors, environmental risk factors, biomarkers, course of illness, shared treatment response.Led to regrouping of disorders in DSM-5.Lifespan ApproachDisorders that are more frequently diagnosed in childhood (i.e. neurodevelopmental) fall at the beginning of the manual and disorders more applicable to older adulthood are found toward end of manual.Within the text of each disorder are descriptions of how the disorder may change across the lifespan.Age related factors specific to a diagnosis are included in the text about the disorder and where applicable, to the actual diagnostic criteria.Cultural ConsiderationsFor specific behaviors, boundaries between normality and pathology vary across cultures and the tolerance for specific symptoms.Determination that a given behavior is abnormal requiring clinical attention will depend on cultural norms.In the text of each disorder is a section titled “Culture-Related Diagnostic Issues” that will identify a variety of cultural issues for the clinician’s consideration.EXAMPLE: In some cultures visual or auditory hallucinations with a religious content are a normal part of religious experience; how depression is expressed or an individual’s perception of what has caused a mental disorder can vary widely across cultures.Gender DifferencesTerm used in DSM-5 to reflect differences in both the causes and the expression of mental disorders as a result of biological sex.More information included on multiple levels to include gender specific symptoms and gender related specifier i.e. perinatal onset of a mood episode.In text of each disorder is “Gender-Related Diagnostic Issues” that addresses other gender issues pertinent to diagnosis and general consideration.Use of Other Specified and Unspecified DisordersPrevious NOS designation now replaced with two options for use by the clinician.“Other specified disorder” - Clinician indicates specific reason that presentation does not meet criteria for any specific category within a diagnostic class; i.e. “other specified depressive disorder, depressive episode with insufficient symptoms.”“Unspecified disorder” – Clinician chooses not to articulate reason criteria not met.Elimination of Multiaxial SystemThe elimination of the multiaxial system has its roots in the DSM-IV which commented that “The multiaxial distinction among Axis I, Axis II, and Axis II disorders does not imply that there are fundamental differences in their conceptualization, that mental disorders are unrelated to physical or biological processes, or that general medical conditions are unrelated to behavioral or psychosocial factors or processes.”Consonant with ICD guidance to consider an individual’s functional status separately from his or her diagnoses or symptom status.Axis I, II and III combined.Axis IV- ICD-9-CM V codes now and then ICD-10 Z codes (10/01/2014).Axis V – The GAF score is eliminated. Clinicians can use the WHODAS for a global measure of disability.In Section III of the DSM-5, the APA offers the use of scientifically validated assessment measures for children and adults. These measures are intended to enhance clinical decision making and not as the sole basis for clinical diagnosis. These assessment tools include:Cross-Cutting Symptom MeasuresDisorder-Specific Severity MeasuresDisability MeasuresPersonality InventoriesEarly Development and Home BackgroundCultural Formulation InterviewsThese tools are available online and can be reproduced and used by clinicians with their patients without permission: http://www.psychiatry.org/practice/dsm/dsm5/online-assessment-measuresINTRODUCTION TO ICD-10-CM International Classification of Diseases, Tenth Revision, Clinical Modification27622443180BackgroundThe International Classification of Disease (“ICD”) is a publication of the World Health Organization (“WHO”).ICD-9 codes in existence for 25 years; becoming obsolete.As procedures advance, current method of coding cannot capture the full extent of procedures performed or treatment rendered. Change to ICD-10-CM is all about data.Purpose to obtain specific data regarding mortality, morbidity and health care crises to be widely shared not only among other countries but also health plans and other providers.Level of detail and clarity found in ICD-10-M should enhance claims adjudication and processing.ICD-10-CM Format and ConventionsDivided into two main sections; the Alphabetic Index which is a list of terms and the corresponding codes and the Tabular List, a sequential, alphanumeric list of codes divided into chapters based on body systems or condition.Index subdivided into indexed sections for Neoplasms, the Table for Drugs and Chemicals and the External Causes of Injury.69,000 codes available - ICD-9-CM was 14,000 codes.Chapters most likely used by behavioral health clinicians:Chapter 5 (“F”) – Mental, Behavioral and Neurodevelopmental DisordersChapter 21 (“Z”) – Factors Influencing Health Status and Contact with Health ServicesChapter 19 (“S,” “T”) – Injury, Poisoning and Certain Other Consequences of External CausesChapter 6 (“G”) – Diseases of the Nervous SystemICD-10-CM codes all begin with a letter and can be alphanumeric throughout remainder of code.Code assigned to the highest level of specificity in its category; codes can be up to seven characters.Some codes valid as three characters; ICD-10-CM manual will guide user in knowing when to add additional characters.EXAMPLE: F70: Intellectual disability; mildF10.239: alcohol withdrawal; without perceptual disturbancesSigns and symptoms: codes that describe symptoms and signs are acceptable to report when a related definitive diagnosis has not been established (confirmed) by the provider.EXAMPLE: Altered mental status (R41.82); Emotional lability (R45.86)Signs and symptoms routinely associated with a disease process should not be assigned as additional codes unless otherwise instructed by the classification.EXAMPLE: Reactive attachment disorder of childhood (F94.1). There is a coding note “Use additional code to identify any associated failure to thrive or growth retardation.”Signs and symptoms not routinely associated with a disease process should be assigned as additional codes when present unless otherwise instructed by the classification.EXAMPLE: Patient with schizoaffective disorder, predominantly depressed, comes for follow-up appointment with complaints of upper abdominal pain. Clinician directs patient to make appointment with their PCP and clinician plans to monitor for follow-up.Schizoaffective disorder, depressive type ( F25.1)Upper abdominal pain, unspecified (F10.10)CDI TIP: Will require more detail in the medical record to assign most appropriate code based on the patient’s signs/symptoms.Late Effects (Sequela) is the residual effect after the acute phase of an illness or injury. There is no time limit on when a sequel code can be used.EXAMPLE: Patient with history of fracture of vault of skull from motor vehicle accident several years ago.Fracture of vault of skull (S02.0XXX)Traumatic brain injury (S06.S) - reflects sequelaPrincipal diagnosis is based on the condition that brought the patient to the hospital or physician office unless the ICD-10 sequencing instructions state otherwise.Resolved conditions or diagnoses that have no bearing on current treatment are not to be reported and are coded only if required by the hospital or physician practice policy.Abnormal test findings are not coded or reported unless the physician indicates their clinical significance.CDI Tip: The appropriate codes for “In remission” are assigned based only on clinician documentation.295275304800DSM-5 AND ICD-10-CM HARMONIZATIONThe ICD – CM codes are used for claims submissions including behavioral health and substance use claims. The DSM is used for clinical and research application with its provision of diagnostic criteria.Follow the coding and recording directions in DSM-5 to ensure the highest level of coding for ICD-10-CM.DSM-5 will direct the clinician the corollary ICD-10-CM codes.The DSM-5 may direct the clinician to record additional specifiers which may not have a corollary ICD-10-CM code. But, also list these as applicable, as there may be additional symptoms/features of the individual’s presentation that can be coded.EXAMPLE: Major Depressive Disorder ICD-10-CM and DSM-5 direct the clinician to note the following: single or recurrent episode, current severity (mild, moderate, severe) presence of psychotic features and remission status (partial or full).DSM -5 further directs clinician to add as many specifiers that apply:With - anxious distress, mixed features, melancholic features, atypical features, mood congruent psychotic features, mood-incongruent psychotic features, peripartum onset, seasonal pattern, * with catatonia ( F06.1).DOCUMENTATION EXAMPLEDSM-IV TO DSM-5/ICD-10EVALUATION # 1AGE: 27 yearsCHIEF COMPLAINTAnxietyHISTORYOF PRESENT ILLNESSHe said that he has been on Adderall for five years via the Town Medical Associates with positive effect. He was recently prescribed Prozac but hasn’t taken it yet. The doctor put him on that for anxiety. He feels depressed. When depressed he feels sad. He denied crying. Concentration improved with Adderall. Memory was poor. Energy and motivation were poor. He feels helpless, worthless and guilty. Appetite is good. Weight is stable. He sleeps about six hours a night and does feel rested. He denied suicide and homicide ideation past and current. He is positive psychomotor retarded. Self-esteem fluctuates. He does have a decreased interest in pleasurable activities. He has had a problem with depression since high school and it has increased recently due to family problems. He feels anxious. When anxious, he feels paranoid and needs to walk away. He has increased heart rate. There is no change in his breathing patterns. Stomach feels tight. He is diaphoretic. Specific anxiety is crowds. He is positive for social anxiety. He says that he feels like he can’t control himself and has to get up and leave. He is agoraphobic sometimes. He feels that he has five panic attacks per week. They last about an hour. He goes from being anxious to panic right away he said. He denied OCD and PTSD. He did admit to major mood swings. He has a history of rapid pressured speech, going from one topic to the next and one project to the next. He has occasional increases in self-confidence and a decreased need for sleep. He denied an increased spending of money. He denied going from being depressed to being irritable or agitated. On intake that appeared to be positive. He denied auditory and visual hallucinations. He is positive for paranoia. He feels that people are talking about him.MEDICAL HISTORYDenied. Allergy is Sulfa.PSYCHIATRIC HISTORYHe was treated somewhere when in high school. He is currently on Adderall immediate release 30 mg. bid. He has a history of being on Lexapro and Wellbutrin which made him feel depressed and gave him a decreased appetite. FAMILY PSYCHIATRIC HISTORYDenied.DRUG AND ALCOHOL HISTORYHe drinks on weekends. He does have a history of alcohol abuse. He has a history of using ecstasy.FAMILY DRUG AND ALCOHOL HISTORYPaternal uncle has problems with drugs and alcohol.PSYCHOSOCIAL HISTORYHe lives with his wife and children. He has a good relationship with them. He has a history of being on probation and has court ordered anger management.MENTAL STATUS EXAMINATIONPatient is a 27 year old married white male. Appearance is consistent with his stated age. He was neat, well-groomed, casually dressed, and appeared as if he just came from work. Speech was normal rate, rhythm and tone. Insight and judgment were poor. Mood was dysthymic. Affect appeared a little anxious. He denied suicide and homicide ideation.DIAGNOSTIC IMPRESSIONAxis I: Attention Deficit Disorder Bipolar Disorder Not Otherwise SpecifiedAxis II: DeferredAxis III: NothingAxis IV: ModerateAxis V:55RECOMMMENDATIONSRisperdal 1 mg. po/q/day.DISCUSSIONPatient is a 27 year old married white male who came to see me today for medication evaluation. Medications were discussed under recommendations. Risk benefits were discussed. Web site given www.safemedication.com so he could look up his meds. I did suggest changing the Adderall to Adderall XR and then Adderall immediate release in the pm. He did not want to do this at this time even though the Adderall would give him better coverage. He said he wanted to look it up. He appeared to be interested in a benzodiazepine. I told him that with his drug and alcohol history that I did not feel this would be in his best interest. We will try the Risperdal to help with mood and anger. He is to come back and see me in one month.DSM-5/ICD-10DIAGNOSTIC IMPRESSIONUnspecified Attention- Deficit/ Hyperactivity Disorder (F90.9)Unspecified Bipolar and Related Disorder (F31.9)Unspecified Anxiety Disorder (F41.9)Alcohol use, unspecified (F10.90)Family history of other substance abuse and dependence (Z81.4)Problem related to primary support group, unspecified (Z63.90)Problem related to unspecified psychosocial circumstances (Z65.9)
How to write DSM 5 diagnosis? a DSM-5 diagnosis of Major Depressive Disorder, Single Episode, Mild (296.21), with Anxious Distress” Note: Given that there is only one disorder the principle diagnosis would be assumed and it is therefore not required to state: Principal Diagnosis. Note: DSM-5 presents diagnostic specifiers in lowercase rather than capitalized letters.