One of the hardest jobs for coders is to translate physician terminology into ICD-10 coding terminology. This has been especially challenging with codes related to mental and behavioral health. In some cases during the year following ICD-10 implementation, there was no way to convert DSM-5 terminology used by psychiatrists and psychologists to ICD-10-CM. Lack of understanding of the differences between the code sets led to misinterpretation and frustration among coders and mental health professionals.
Effective Oct. 1, 2016, the Centers for Medicare & Medicaid Services (CMS) introduced thousands of new ICD-10 codes, including 14 codes related to mental health. According to a publication by the American Psychiatric Association (APA), these include changes to align the terminology used in DSM-5 with that which is used in the mental health chapter of ICD-10. Many of the changes to the mental health codes relate to new or additional specifiers listed after the decimal point of the parent code.
For example, category code F42, Obsessive-compulsive disorder, was changed to include five subcategories that describe specific types of obsessive-compulsive disorders. One of these, hoarding disorder, is now coded to F42.2. Prior to the updates, hoarding disorder could not be coded in ICD-10-CM even though it was a recognized disorder in DSM-5. Also noted in the release, excoriation (skin-picking) disorder and premenstrual dysphoric disorder now have appropriate F codes in the mental health chapter. In the past, these disorders could only be classified to more general medical categories such as L for skin and N for genitourinary, respectively. Billing under L or N codes today could lead to denials when submitted by mental health providers.
In addition, the latest coding guidance from Coding Clinic, published by the American Hospital Association (AHA), appears in the recently released issue for the fourth quarter of 2016. It includes extensive clarification of the new codes and examples of how to use them. Here are some of the most significant changes and the implications for coders, providers, payors, and patients.
- Premenstrual dysphoric disorder, F32.81: Before the updates, if a physician used this term, ICD-10-CM classified the disorder with a code for the less severe premenstrual tension syndrome, rather than a code needed for a more serious psychological disorder.
- Disruptive mood dysregulation disorder, F34.81: Characterized by severe recurrent temper outbursts, this disorder was previously coded to general terms such as unspecified mood disorder, which was too broad and included all of the symptoms associated with many known types of mood disorders.
- Hoarding disorder, F42.3: Physicians had been using the term prior, but there was no code other than the general code for obsessive-compulsive disorder. Hoarding is now recognized as a separate and distinctive disorder.
- Excoriation (skin-picking) disorder, F42.4: Previously coded in general terms such as psychogenic skin disorder or mistakenly under neurotic excoriation, excoriation disorder is now more accurately coded as a type of obsessive-compulsive disorder.
- Binge-eating disorder, F50.81: Characterized by out-of-control eating, this disorder was previously “crosswalked” to the code for anorexia nervosa. Now, binge-eating has its own billable/specific code that can be used to indicate a diagnosis for reimbursement and more precise diagnostic and tracking purposes.
- Transsexualism, F64.0: A new code titled transsexualism has been added to the old category of F64. The title of the old code F64.1,Gender identity disorder in adolescence and adulthood, was changed to dual-role transvestism. The title was revised to align terminology with both DSM-5 and the World Health Organization (WHO) international version of ICD-10.
- Social (pragmatic) communication disorder, F80.82: This disorder was recognized in DSM-5, but there was no ICD-10 code for patients who have verbal or nonverbal communication problems yet are not characterized by low cognitive ability.
- Activity, choking game, Y93.85: ICD-10-CM previously did not provide an activity code to identify the choking game, also known as the fainting or blackout game, other than the old, general code for activity other specified. Now, code Y93.85 can be used to highlight a condition presenting as a result of the choking game – describing the circumstance causing an injury, not the nature of the injury. This change helps tremendously with tracking the frequency and patterns of such injuries.
Coding Updates Support Compliance
Coding audits often reveal areas that require further specification and clarification – it’s part of the process. For example, in recent years we found that mental health providers were not using terminology we were accustomed to using for substance abuse or dependence. Instead of using the terms “abuse” or “dependence,” providers often use more current DSM-5 terminology describing the patient’s substance use as a “substance use disorder,” qualified as mild, moderate, or severe. In the past, we lacked descriptions and detailed criteria in ICD-10-CM to accurately code a mild, moderate, or severe substance use disorder, not described as abuse or dependence, resulting in confusion and potentially misleading codes. Should we code alcohol use disorder simply as alcohol use? How should we code the various degrees of cocaine use – mild, moderate, severe? In addition to code changes, the new updates changed the index, which now leads to the right code.
As of Oct. 1, through index changes and new inclusion terms, we now have a reliable crosswalk that translates DSM-5 terminology for mild, moderate, or severe substance use disorders to the proper ICD-10-CM codes. For example, per the index under Disorder, cocaine use, mild indicates abuse. Moderate or severe indicates dependence. Another relevant example involves alcohol use. Before the change, coders used F10.99 (alcohol-induced problem) to code alcohol use. We now are directed by the index to use Z72.89 (other problems related to lifestyle), which is unspecified but more accurate, and billable, for moderate alcohol use that is not considered a disorder.
One of the greatest advantages of the updates is alignment with terminology used by all practitioners in community facilities, not just psychiatrists and psychologists. The ability to use a specific, billable ICD-10-CM code aligned with physician terminology to indicate a proper diagnosis for reimbursement purposes brings huge benefits for coders, providers, payors, and patients:
- Improves overall productivity and accuracy
- Reduces the need to query physicians
- Promotes accurate and timely reimbursement
- Improves patient care and satisfaction
- Advances data integrity – accurate data capture, analysis, and reporting
- Guides proper diagnoses and treatment
- Supports effective preventative programs
- Strengthens clinical documentation improvement
While awareness of updates is a critical first step for all stakeholders, optimal benefits are realized through training and education based on new requirements that affect quality of care and reimbursement. Organizations with a proactive plan to ensure up-to-date knowledge and skills for coding staff will be well-prepared for year two of ICD-10 implementation.
Codes: Old versus New
The chart below lists examples of the original and new ICD-10-CM codes for the mental health disorders affected.
|Disorder||Original ICD-10-CM Code Options
(Valid until Sept. 30, 2016)
(Effective Oct. 1, 2016)
|Binge-eating disorder||F50.02 (with anorexia nervosa)||F50.81|
|Disruptive mood dysregulation disorder||F39||F34.81|
|Excoriation (skin-picking) disorder||F54 or L98.1||F42.4|
|Gender-identity disorder in adolescents and adults||F64.1||F64.0|
|Hoarding disorder||No available code||F42.3|
|Other specified feeding or eating disorder||F50.8||F50.89|
|Premenstrual dysphoric disorder||N94.3||F32.81|
|Social (pragmatic) communication disorder||No available code||F80.82|
|Activity, choking game||Y93.9||Y93.85|
|Alcohol use NOS||F10.99||Z72.89|
|Alcohol use disorder, mild||No available code||F10.10|
|Alcohol use disorder, moderate or severe||No available code||F10.20