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Getting (and keeping) the money: Understanding the ICD-10 landscape

November 17, 2014
by Lisette Wright
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As I continue to teach the curriculum, “ICD-10 and DSM-5: Coding, Documentation, and Clinical Diagnostic Criteria Training©” to separate audiences, not much has changed: behavioral health and substance use clinicians, administrators, quality, compliance, and billing offices are not prepared for the ICD-10 transition, slated by CMS to go into effect October 1, 2015. Many persist in thinking that their EHR (electronic health record) or billing clearinghouse will magically take care of everything. Many do not understand how very different the ICD-10 and DSM-5 are from each other.

Virtually no one learned about ICD in graduate schools nor did the novice clinicians of today coming in to your organization. People are toting their purple books to my trainings only to question its reliability in the new world of ICD-10 and usefulness for 5010 healthcare claims moving forward (it is still a great book for other reasons). Many have not realized that the purple book has already been updated. Finally, those top 20 organizational diagnoses are still predominantly “NOS” or “Unspecified” diagnoses when reports are pulled.

Crosswalk not ideal solution

Some behavioral health EHRs are programmed to only offer a DSM diagnosis and the billing office personnel (not certified coders) are then “crosswalking” those codes to ICD-9 (or ICD-10 eventually). Who is assigning the diagnosis then?

Some state Medicaid organizations, county governance boards, and others think that needing to know the differences between the types of BiPolars is not going to be that big of a deal. More concerning are the “ICD-10” trainings out there that do not cover the level of specificity or coding rules that will be required moving forward. Or the DSM-5-only trainings that many people attend thinking they will understand ICD-10.

My audiences know I am manual agnostic and that I have said all along we will need both code sets moving forward. Does this create a false sense of reassurance because the DSM-5 “contains” ICD-10 codes? We are the only set of healthcare providers in the US that must use two diagnostic code-sets concurrently when ICD-10 goes live. We have a burden on us that others do not have to reconcile. Revamping clinical policies and procedures is non-negotiable moving forward if you want to keep your money. More importantly are the clinical documentation and coding rules that will now be enforced in this industry like never before.

Some specific examples:

  • Some third-party payers will not reimburse for “Other” or “Other Unspecified” codes
  • There are very specific rules about when you can assign an “Unspecified” code
  • F20.9 in the DSM-5 is the single diagnosis for schizophrenia. However, F20.9 in ICD-land is “Schizophrenia, Unspecified.” And what about the 5th coding digit for the 8 different episodes of schizophrenia in the ICD-10 now required?
  • Both the ICD and DSM say to “Code First” any medical condition that contributes to the mental health condition. What is your Policy and Procedure around this documentation requirement?

Whether or not we jump right to ICD-11, everything above still applies. This monumental transition in our industry will not go away with a jump to ICD-11. Payers and auditors are sorting it out on their end too, some very eagerly. There is still time to figure this out. Waiting until September 2015 is not a fiscally-sound option for your organization. 

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Lisette Wright

IT Consulting for Health and Human Services

Lisette Wright

@lisettewrightmn

www.behavioralhealthsolutionsmn.com

Lisette Wright, M.A., LP has over 20 years of experience in the healthcare...