August 2015

The ICD-10 is the World Health Organization’s (WHO) current version of the International Classification of Diseases diagnostic coding system. It is used worldwide to capture information about all diseases and health conditions, not just mental health. The ICD-10-CM (10th Revision — Clinical Modification) is a modification of WHO’s international version designed specifically for use in the United States. 

The following material is based on questions about ICD-10-CM that members have raised with APA Practice staff.

Is the Oct. 1, 2015, implementation date for ICD-10-CM firm?

Yes. There is no indication that implementation will be delayed beyond the scheduled Oct. 1, 2015, date for transition from ICD-9-CM to ICD-10-CM.

Who has to comply with ICD-10-CM?

All health care providers covered by the Health Insurance Portability and Accountability Act (HIPAA) are required to comply and must use ICD-10-CM codes in diagnostic coding on electronic and paper claims for services provided on or after Oct. 1, 2015.

What are the benefits of converting to the ICD-10-CM?

Diagnostic codes in the ICD-10-CM incorporate more clinical detail than the ICD-9-CM system in use through Sept. 30, 2015, and therefore better capture the clinical portrait of each individual case. The many benefits include:

  • U.S. will join most other countries in using the same version of ICD.
  • Same code set facilitates communication, especially for international patients.
  • Uniform, more detailed, code set across all of health care.
  • Greater specificity for substance use disorders and in other physical health domains.
  • Space to accommodate future code expansions.
  • Ability to track progressions and regressions in diagnostic severity.
  • Ability to integrate existing computer-assisted, ICD-10-CM coding programs that demonstrate more accurate and efficient coding.
How is ICD-10-CM different from ICD-9-CM?

The ICD-10-CM addresses many of the limitations of the ICD-9-CM and reflects advances in terminology, treatment and research developments. Additionally, while the brief format of the ICD-9-CM codes limited the ability to expand the code set to allow for emerging developments, the ICD-10-CM code set enables routine annual updates. 

There are substantially more ICD-10-CM codes than ICD-9-CM codes. While the expansion of the mental health-related codes is not as extensive as for other areas, the substance use codes are more detailed. 

The new codes are longer and therefore provide for more detail in recording diagnoses. The ICD-10-CM codes are made up of three to seven alpha or numeric digits. The first digit is alpha, the second is numeric and the following digits are either alpha or numeric. 

ICD-10-CM seems voluminous. Do mental health professionals need to use all of the codes?

The classification system is designed to meet the needs of all types of health care professionals. Mental health providers will not need to use most of the codes in the classification system; in fact, they generally will only need to use a subset of ICD-10-CM codes that largely come from Chapter 5: Mental and Behavioral Disorders. Other chapters of relevance may include:

  • Chapter 6: Diseases of the Nervous System.
  • Chapter 18: Symptoms, Signs and Abnormal Clinical and Laboratory Findings.
  • Chapter 21: Factors Influencing Health Status and Contact with Health Services.
Can we begin to use the ICD-10-CM codes before the Oct. 1, 2015, compliance date?

No. Claims using ICD-10-CM codes prior to Oct. 1, 2015, will be rejected. ICD-9-CM diagnostic codes must be used on claims for services provided through Sept. 30, 2015.

How should claims that begin before and extend after the compliance date of Oct. 1, 2015, be billed?

The answer to this question depends on the type of claim filed as the requirements differ according to facility type and services provided. For example, some payers may require that the claims be split and billed under the ICD-9-CM code before the compliance date and under the ICD-10-CM code on and after the compliance date. Refer to a comprehensive document published by CMS (MLN Matters® Number: MM7492) for specific directions that fit your circumstances. This resource can be accessed directly via CMS (PDF, 192KB).

I do not participate with any third-party payers. Do I still need to include ICD-10-CM codes on my patient bills?

Patients seeking insurance reimbursement on their own behalf will need the applicable ICD-10-CM codes on their bills.

I have heard that there might be a “partial code freeze.” What is this?

Annual updates are made regularly to the current version of the ICD. However, in response to concerns about converting to a system that would be actively undergoing changes, the ICD Coordination and Maintenance Committee implemented a partial code freeze in effect until one year after the implementation of the ICD-10-CM — Oct. 1, 2016. Until then, only very limited updates (that address new technology and diseases) to the ICD-10-CM codes will occur; most codes will be “frozen” without changes or updates. More information is available from CMS (PDF, 21KB).

What degree of specificity is required when I am coding?

It is important to be as specific as possible in selecting ICD-10-CM codes — that is, when known, use the code structure to indicate severity or other meaningful diagnostic information. However, CMS has said that Medicare contractors will not deny claims based solely on the specificity of the ICD-10-CM code chosen. The claim must contain a valid ICD-10-CM code from the “right family” of codes related to the service provided.

I have an assistant who identifies billing codes reflecting my documentation. What types of changes might I need to make to patient record keeping to help ensure accurate diagnostic coding?

Documentation needs to be detailed and specific. It is important to include the degree of persistence associated with the symptoms, including the acute or chronic nature, along with specifiers of the clinical presentation and origins. For example, substance use coding now begins by selecting the code for a discrete substance (for example, cocaine, marijuana). 

Here is another example. In the ICD-9-CM, conversion disorder entailed only one code. However, coding for the same disorder in the ICD-10-CM requires much more detail. This detail must be extractable from clinical documentation and patient records.

ICD-9-CM

Disorder Code
Conversion Disorder 300.11

ICD-10-CM

Disorder Code
Conversion disorder with motor symptom or deficit F44.4
Conversion disorder with seizures or convulsions F44.5
Conversion disorder with sensory symptom or deficit F44.6
Conversion disorder with mixed symptom presentation  F44.7
Other dissociative and conversion disorders  F44.89
Dissociative and conversion disorder, unspecified F44.9

Is ICD-10-CM difficult to navigate?

Although it will seem unfamiliar at first, the ICD-10-CM follows a logical structure. 

The American Psychological Association Practice Organization (APAPO) has provided several resources to assist members in making a smooth transition to the ICD-10-CM coding system. For examples, members have access to a Web-based application free of charge that provides information about the ICD-10-CM, featuring diagnostic codes for Chapter 5. Users are able to navigate content by searching for key words, browsing a list of featured ICD-10-CM diagnoses or exploring several graphical interfaces. Members can use the application by logging in at my.apa.org and going to “Practice Tools.” 

Additional resources from the Practice Organization can be accessed via our website.

Will I be able to use “unspecified” diagnostic codes after the ICD-10-CM implementation date?

Mental health professionals are expected to provide the most detailed level of diagnosis possible at the time the patient is seen. It is preferable to code as much specificity as possible which may simply include coding the symptoms the patient is experiencing. 

Unspecified codes do exist in the ICD-10-CM throughout most chapters and may be used if no other codes are applicable. However, these codes run a higher risk of being flagged during claim audits, and payers may require documentation to justify use of an unspecified code.

Is there a “crosswalk” document available to assist in the transition?

We are planning to include a crosswalk document with the more commonly diagnosed disorders in the Fall 2015 issue of Good Practice magazine from the APA Practice Organization. This will assist practitioners with the challenge of converting existing coding to the new code set. 

However, it is imperative to note that the two systems do not overlay perfectly. As with conversion disorder, one code in ICD-9-CM might conceivably map to two or more codes in ICD-10-CM and psychologists therefore will need to have sufficient documentation to make those finer determinations. For this reason, familiarization with the new coding set is of utmost importance, especially throughout the implementation process. 

The APA Practice Organization is committed to continuing to serve as a resource for members throughout the transition to ICD-10-CM. Additional information can be accessed at the Legal and Regulatory Compliance section of our website.

The following links related specifically to ICD-10 may also be helpful:

How should psychologists determine diagnoses going forward?

The ICD-10-CM will be the required code set for billing purposes. Arriving at a diagnosis is the function of the psychologist independently assessing the individuals who seek care. Most psychologists have been trained to use the DSM diagnostic criteria for that purpose and the current DSM-5 does contain both ICD-9-CM and ICD-10-CM codes. The ICD-10-CM does not have extensive criteria for the purposes of diagnosis. It is presumed that the health care professional has that knowledge, or access to that knowledge, and the expertise to use that knowledge appropriately. Psychologists might access that content through the DSM or through other resources such as the professional literature, practice guidelines or other accepted sources.

What about diagnostic classification and coding outside of health care billing, reimbursement and HIPAA?

Federal education laws, such as No Child Left Behind, have requirements for Individualized Education Programs and special education, but regulations do not mandate DSM or any other diagnostic manual. The laws leave it to states to define the criteria for diagnostic coding. 

While many states do not specify criteria and indicate professional expertise as the determinant, some state laws and regulations do specify DSM. In other states, DSM may be utilized to arrive at a diagnosis but it appears a professional could also use other methods to arrive at a diagnosis. If the DSM is written into either state law or regulation, psychologists will want to know what the law states and be certain they are following them accordingly.