ICD-10 AND DSM 5 TRANSITION

In an effort to provide some information regarding the impending transition between ICD-9 and DSM IV
to ICD-10 and DSM 5 the VACSB QM and DMC committees have worked to provide this guidance
document. Please note this is not all inclusive and is meant to serve as guidance only. If you have any
questions please contact Heather Rupe (hrupe@nrvcs.org) - QM Committee Chair, or Mike Forster
(mike@hrcsb.org) – DMC Chair.

The Centers for Medicare and Medicaid Services recommends developing an implementation strategy
that includes an assessment of the impact on your organization, a detailed timeline, and a budget. Check
with your billing service, clearinghouse, or practice management software vendor about their compliance
plans. It is important to implement staff training on the appropriate use of ICD-10 codes, modifications to
your billing procedures that accommodate ICD-10, and to determine if your electronic health record
provider is making the appropriate systems updates so that you will be ICD-10 compliant on October 1,
2015.

GENERAL INFORMATION

What things do I need to consider?

- There are several areas regarding the transition that need consideration. They include:
o Training options
 What staff to do I include?
 What do I train on?
 Is it mandatory?
o Current Diagnosis Analysis
o State Reporting
o EHR options
o Payer Testing
o Timelines
o What resources do I have?

Why the transition?

- The ICD-10 update reflects the current clinical understanding and technological
advancements of medicine, and the code descriptions are designed to provide a more
consistent level of detail. It’s more specific, and encapsulates a more extensive vocabulary.
- The DSM 5 is also more detailed, adds new diagnosis and includes more specificity.
What’s new about the ICD-10?

- ICD-10-CM/PCS (International Classification of Diseases, 10th Edition, Clinical Modification/

Procedure Coding System) consists of two parts for diagnosis (CM) and inpatient procedure
coding (PCS). Diagnosis coding under ICD-10-CM uses 3 to 7 digits instead of the 3 to 5 digits
used with ICD-9-CM and the format of the code sets is similar. ICD-10 coding is much more
specific and detailed in terms of diagnoses and can be used for pay-for-performance and bio
surveillance.

What’s new about the DSM 5?

- Changed from Roman numeral to Arabic (V to 5). The DSM 5 discontinues the use of the
mulitaxial system for diagnostics. Additionally the DSM 5 adds some gender specific
symptomology. The NOS (not otherwise specified) designation has been replaced with two
other specifications: Other specified disorder or Unspecified disorder. There are many small
changes including name changes, specifier changes, age cutoffs and textual changes.

Why is this different than ICD-9 and DSM IV?

- The ICD-9 and DSM IV were compatible in that they used the same set of codes. Therefore
it was seamless from service authorization to billing; from clinical staff to reimbursement.
However the DSM 5 and ICD-10 are not as seamless. They use a different coding structure.
On the clinical side with documentation and authorizations it is still expected from payers
that the DSM 5 diagnostic criteria and language are present as well as the specificity of the
ICD-10 codes. However the reimbursement side will utilize the ICD-10 codes.

When do I have to make the transition?

- Oct 1, 2015 is the date for transition from ICD-9 to ICD-10. For services rendered Oct 1,
2015 or AFTER reimbursement systems will utilize ICD -10 codes. For services rendered
PRIOR to Oct 1, 2015 ICD-9 codes must be utilized, even if the billing date is Oct 1, 2015 or
after.
- For services that span a length of time, if the end date is Oct 1 or after then ICD codes would
be used. (For an example and inpatient stay where the discharge date is on or after Oct 1,
2015)
TRAINING

Training will need to occur on various levels. Due to the unique circumstances surrounding the
transition it is likely training should occur around both the DSM 5 and the ICD-10.

Who do I need to train?

- Training will need to occur for most staff on both the DSM 5 and ICD-10.
- This include clinical, administrative and billing staff
- It’s likely that dependent on the level of staff you may need to provide training on a basic as
well as advanced level

What information do I include?

- Training will need to include the updated diagnostic criteria for DSM 5 including specificity.
The DSM 5 manual includes the ICD-10 codes in parenthesis to provide some consistency
across manuals. Clinical staff will need a review of the documentation criteria for the DSM
5. It is expected that clinical documentation has clear indication of diagnosis based on the
DSM 5 criteria as well as the ICD-10 specificity.

CURRENT DIAGNOSIS ANALYSIS

It is recommended that you do an analysis of your current DSM IV/ICD-9 Diagnosis that you are
currently using. It is likely that most of the Diagnosis you are using have 1 to 1 mapping (using the
GEM Crosswalk) to an ICD-10 Code. This will be helpful to know and in planning for the transition of
current clients Diagnosis.

STATE REPORTING CONSIDERATIONS

 Starting in the July 2015 data submission CCS will begin accepting ICD-10 codes in addition
to the current DSM IV codes.
 For the October 2015 data submission CCS will require ICD-10 codes for all active clients.
For closed clients CCS will accept either ICD-10 or DSM IV codes.
 Starting in the July 2016 data submission CCS will ONLY accept ICD-10 codes
ELECTRONIC HEALTH RECORD CONSIDERATIONS

What questions do I need to ask my EHR vendor?

- There are several things to consider with the EHR conversion to ICD-10/ DSM 5.
o Is the vendor ready for the conversion?
o Do you have a test environment to be able to send test claims?
o Will the system accommodate billing for dates of service prior to Oct 1, 2015 after the
conversion is made? What does that entail?
o Will any current diagnosis in the system update to the suggested counterpart in DSM
5 or ICD 10? If there isn’t a 1 to 1 match what options do you have for updating them?

What is GEM?

- General Equivalence Mapping (GEMs) are a tool to assist in the bidirectional conversion of the
ICD-9 to the ICD-10 codes and vice versa. They are public and are offered to providers to
assist in converting and testing systems. GEMs are not an automated crosswalk. But utilizing
these can be helpful in developing a business process to create a specific crosswalk.
- GEM for ICD-9 to ICD-10 will not identify the best match, but will instead provide you with a
range of choice that requires some judgment to be applied.

PAYER TESTING

When will payers be able to accept my codes?

- Many payers now are able to accept DSM 5 codes. However they will not be able to accept
any ICD-10 codes until Oct 1, 2015 for services rendered Oct 1, 2015 or after.
- Magellan has noted they will be ready for test claims as early as June, but will notify providers
when testing is ready to begin.

Where do I start with Payers?

- Begin by contacting your payer(s) to inquire about payer readiness to accept codes.
- You may want to review your contracts with payers to determine what the expectations of
your billing staff is and what is the responsibility of the payer.
- Inquire about the expectations of the payer in testing and ability to send test claims.

What should I do to prepare for testing?

- Identify the most commonly used ICD-10 codes for your organization
 - Create and code test claims (A suggested starting point would be dual coding a few claims
with ICD-9 and ICD-10 codes every day)
- Make a request of payers to allow a testing sample
- QA- utilize this time to evaluate the completeness of the clinical documentation to ensure the
DSM 5 and ICD-10 codes is supported.
- Work with your IT dept to make sure the full range of ICD-10 codes are available for use.

Are there budget considerations?

- It is suggested that you prepare a cash flow analysis related to the challenges. There may be
a delay in payments as a result of coding challenges with billing and authorizations.

SUGGESTED TIME LINE

April 2015

- Develop transition team

- Begin communication will all staff regarding transition
- Review clinical record and workflows to identify where a Dx may need included

May 2015

- Review current diagnosis for current consumers to determine what impact may be on
current services
- Communicate with EHR vendors regarding the use of DSM 5 criteria in the system
- Begin basic training efforts including developing a sandbox/testing system for clinical and
billing staff

June/ July 2015

- Test ICD -10 CCS3 Submissions

- Continued training efforts including more advanced training for those identified
- Prepare for Payer testing, communicate with payers, develop test claims, implement dual
coding etc.

August/ September 2015

- Payer testing
- Continued training
- Quality review efforts for clinical documentation
- Update necessary forms

October 1, 2015

- Go Live
RESOURCES

- Coding Behavioral Health Services: CPT, DSM, and ICD

http://www.thenationalcouncil.org/topics/coding-behavioral-health-services/

- ICD9 to ICD10 Code Translator https://www.aapc.com/icd-10/codes/

- Transition to ICD-10: What it Entails and Why It’s Important to Behavioral Health Providers
http://store.samhsa.gov/shin/content/SMA14-4804/SMA14-4804.pdf

- DSM-5 and ICD-10 Implementation http://www.magellanprovider.com/getting-paid/dsm-

5icd-10.aspx

- “Preparing Your Organization for ICD-10 Implementation,” Michael Flora and David Swann,
February 2014. Slides and recording

- Transition to ICD-10 http://www.thenationalcouncil.org/wp-

content/uploads/2013/01/ICD10_onepager.pdf

- Code Handout for Physicians and Providers (DSM-5 and ICD-10-CM

Codes)http://www.justinkhughes.com/professionals.html