Nine frequently asked questions about DSM-5 and ICD-10-CM

APA Practice staff answer questions about billing, determining diagnoses and more related to the two diagnostic classification systems.

By Practice Research and Policy staff

A new edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association, is expected to be released late in May 2013. Transition to using the ICD-10-CM, published by the World Health Organization in the U.S., is currently set for Oct. 1, 2014. This article answers some of the most frequently asked questions received by APA Practice Directorate staff about use of these two diagnostic classification systems.

1. What code set should be used for billing?

The Feb. 28 PracticeUpdate article on ICD-10-CM describes the current coding system used for billing and the change that will occur Oct. 1, 2014. As noted, the Health Insurance Portability and Accountability Act (HIPAA) requires ICD diagnostic codes, not DSM. Since the current ICD in use in this country is "harmonized" with DSM-IV-TR, the codes are essentially the same.

This will change with DSM-5 (although we can't tell you how precisely as we do not have a final version of DSM-5) and we do not know how similar DSM-5 will be to either ICD-9-CM or ICD-10-CM. The American Psychiatric Association will likely develop "crosswalks" between DSM-5 and ICD for those who continue to use DSM-5. Instacode Institute offers an FAQ about DSM and coding online.

In the meantime, however, for coding purposes required for billing, psychologists should continue to use the ICD code set they are currently using (ICD-9-CM which is essentially the same as DSM-IV-TR). We can find no evidence that federal requirements for diagnostic codes for billing will be anything other than ICD.

2. Are you sure DSM-5 won't be required?

As we understand it, insurance companies must follow HIPAA, and ICD is the HIPAA-compliant code set. We are reaching out to contacts both at insurance companies and practice management software vendors to find out whether their systems will crosswalk codes, contain both code sets or otherwise facilitate practitioners' use of one or the other system.

3. How should psychologists determine diagnoses going forward?

Psychologists are licensed to independently assess and diagnose the individuals who seek care from them. Most psychologists have been trained using the DSM for that purpose and, upon the publication of new editions, have simply bought the most recent edition of the DSM in order to be certain they are using the current criteria for diagnosis.

Because these diagnoses must be conveyed in terms of ICD codes, psychologists must have some familiarity with ICD or use a crosswalk from some other system (such as DSM) to ICD in order to identify the appropriate codes and be paid for their services.

The World Health Organization, publishers of the ICD, have created the "blue book" — the ICD-10 Classification of Mental and Behavioural Disorders Clinical Descriptions and Diagnostic Guidelines (PDF, 1.3MB) — which psychologists can use to determine diagnoses. Be aware, however, that many users find that this document does not have the same level of detail that the DSM contains.

Other clinical descriptions and diagnostic guidelines could also be used to arrive at a diagnosis. As noted, the ICD is the code set used for classification and billing purposes, but the ICD itself does not contain 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.

State psychological associations may also offer workshops on diagnoses for their members. Additionally, training programs will need to think through these issues very carefully. Students/ interns/post docs will need to be prepared to diagnose and develop case conceptualizations and they will also need to be able to use the appropriate HIPAA code set (ICD) for billing purposes.

4. 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 (IEPs) and special education, but the text of those bills does not mandate DSM, or any other diagnostic manual. The laws leave it to states to define the criteria for admission.

While many states do not specify criteria and indicate professional expertise as the determinant, some state laws and regulations do specify DSM. From our understanding of the implementation of these federal laws, DSM may be utilized to arrive at a diagnosis but it appears a professional could also use other methods to arrive at a diagnosis.

However, any other method used should be recognized as legitimate, such as the ICD. One could argue that ICD and DSM have a similarity of function and therefore ICD could be used, even if DSM might be the classification written in to the state law. If the DSM is written into either state law or regulation, psychologists will want to know what the law states are and be certain they are following them accordingly.

We are looking into the question regarding the change in autism spectrum diagnoses (for example, the elimination of Aspergers from DSM-5) and the implication for this change for IEPs and other educational purposes.

5. What will psychologists need to do when DSM-5 comes out?

At this point, it appears that members do not need to do anything when DSM-5 is published. APA Practice staff will review the DSM-5, along with ICD-9-CM and ICD-10-CM (already available online) to identify differences.

Practically speaking, for billing, psychologists should continue to use the code set they are currently using. There is no immediate need to learn a new code set.

6. What does the CM and the number mean in ICD?

Every country is allowed to modify the ICD to suit its own particular circumstances. The Centers for Disease Control has that responsibility for the U.S. and the modification that is produced is tagged with "CM" — meaning clinical modification. The number indicates which version the U.S. is using.

It is important to note that WHO published ICD-10 in 1992 and most countries in the world have converted to ICD-10 since that time; the U.S. has not. The U.S. is not scheduled to convert until Oct. 1, 2014, though WHO anticipates publishing ICD-11 in 2015. The CDC hopes to use an annual updating process to bring ICD-10-CM closer in alignment to ICD-11 so that the conversion from version 10 to 11 will not take as long nor be as abrupt with the next transition process. However, for now, psychologists should focus solely on the transition to the ICD-10-CM.

7. Why do these two systems exist?

The American Psychiatric Association publishes a diagnostic manual on mental disorders that has been widely used for training and diagnostic purposes across mental health professions. The rest of the health care industry has used the ICD for diagnostic codes.

The U.S., as a member of the World Health Assembly, is expected to report morbidity and mortality data using the World Health Organization's international standard, the ICD. To the extent that DSM and ICD have been harmonized, that has not been a problem in years past. To the extent that these systems diverge in the future, health statistics such as morbidity and mortality data will be required to be reported to WHO via ICD.

8. What resources is APA developing?

APA's continuing education (CE) office has a presenter under contract who is willing to travel to sponsoring agencies, organizations, or associations who are interested in more intensive training in relation to either the DSM-5 or the ICD. The APA Office of CE in Psychology is co-sponsoring these workshops for CE credit. Interested individuals should contact Marcia Segura.

Programs on the ICD will also be offered at the 2013 APA convention in Honolulu, July 31-Aug. 4.

Former APA President Carol Goodheart, EdD, is authoring a primer on ICD that APA expects to publish in late summer or fall of 2013.

9. What other information have APA and the APA Practice Organization (APAPO) developed on DSM or ICD?

Stay tuned to future issues of the PracticeUpdate e-newsletter for more timely and pertinent information about the DSM-5 and ICD-10-CM.