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What is ICD-10 compliance in behavioral health?

October 19, 2015
by Lisette Wright
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So far, all indications are that the ICD-10 transition is going fairly smoothly. There are some provider organizations that did nothing to prepare for ICD-10 then questioned why their billing programs were “frozen” when they tried to bill after October 1. As predicted, they were among those who felt that ICD-10 did not apply to behavioral health. They are now scrambling to sort things out.

But what does “going smoothly” mean? It likely means this: You submit a claim with an ICD-10 code, and it gets paid by the insurer. There are no delays in payment or reductions in reimbursements. The money gets deposited via electronic funds transfer like it always has, and all is well with the world. These are the reports I am hearing in the industry, which is relieving.

Is this sufficient? It depends. Here is a checklist for ICD-10 compliance:

  • Policy and Procedures: Has the organization formally incorporated relevant ICD-10 items into their compliance program or created a new policy to address the unique needs of the ICD system (and additional utilization of the DSM)? This includes a clear statement about the official process for validating that all codes are accurate.
  • CMS Coding and Documentation Guidelines: Has the staff been trained on these, and are they being followed? What audit tools must be used for tracking and continuous process improvement? Has the intended utilization of these guidelines been delineated in the organizations policy and procedure document?
  • Clinical Documentation: What is the ongoing process for ensuring the most specific diagnosis is both assigned and substantiated?
  • Utilization of All Codes: What is the organization’s policy about incorporating medical, psychosocial and other diagnosis codes? This can be particularly tricky if you are a health home certified by your state, or are considering obtaining Certified Community Behavioral Health Center status.

In the new world of health information technology, it is imperative that consumers be assigned accurate diagnoses for treatment and continuity purposes. Reading about a situation in the narrative portion of a medical record can be cumbersome. Many providers will glance at the patient’s “face sheet” and see the itemized diagnoses. ICD-10 finally gives us a common language and leverage to improve our ability to communicate with other disciplines.

Finally, it is incumbent to know that during this first year of ICD-10, the federal government has indicated some “flexibility” in reimbursing for “unspecified” codes. Just because you are getting paid for “unspecified” codes now does not mean you will when the first year is up. The training of your clinical staff for the ICD-10 coding and documentation guidelines and for the actual codes themselves is still a critical part of an organizations ongoing compliance program. Be proactive and don’t learn the hard way.


Lisette Wright

IT Consulting for Health and Human Services

Lisette Wright



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

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