Here's What CMHCs Need to Know About the New ICD-10 Codes
By Gary G. Gintner, PhD, Louisiana State University
ON OCT. 1, 2014, THE CODES that clinical mental health counselors (CMHCs) use to report diagnoses of clients and request reimbursement from insurance companies will change. In my view, this change is reasonable, positive, and long overdue. Here’s why.
The International Classification of Diseases (ICD) is designed to classify morbidity (illness and injury) and mortality (death). ICD-1 was published in 1900. In 1948, the World Health Organization (WHO) took over management and updating of the ICD. ICD-6, which was published that year, was the first ICD to include a section on mental disorders. WHO member countries have agreed to use the ICD for reporting causes of mortality, morbidity, and other health information. In this way, WHO is able to track causes of disease, death, and related healthcare utilization worldwide.
Once a treaty country adopts the current version of the ICD, it can adapt its own version—make a clinical modification, or “CM”—based on its needs. The version of the ICD currently in use in the United States is the ICD-9-CM, which went into effect in the late 1970s.
The United States did not opt—until now— to adopt the ICD-10, which was first released in 1992. The ICD-10 will take effect in the United States on Oct. 1, 2014. On that date, the nation’s healthcare system will completely shift over to ICD-10 codes. These will then be the HIPAA-approved codes required in healthcare and used by insurance companies, Medicare, Medicaid, and other health agencies.
How Will The Change Affect Your Practice?
Although the ICD-10 will contain about five times the number of current disease codes—70,000 codes, up from about 15,000—only one chapter of the ICD-10 is on mental disorders, so the overall number of new codes relevant to CMHCs is not overwhelming.
Once the ICD-10 codes take effect on Oct. 1, the DSM-5 will not be obsolete. DSM-5 has anticipated the shift by providing two code numbers for each disorder. Here’s an example for Post-Traumatic Stress Disorder: 309.81 (F43.10). The five-digit number in boldface is the ICD-9-CM code that will be in effect until the end of September. The DSM-5 also provides an ICD-10 number, which appears in parentheses.
Notice that the ICD-9-CM code is a straight numerical codes. The ICD-10 code, on the other hand, begins with the letter “F,” reflecting the chapter that they are from in the ICD on Mental, Behavioral, and Neurodevelopmental Disorders. Also, ICD-9 V codes will change to Z codes. Thus, DSM-5 has “crosswalked” the ICD-9 to ICD-10 changes for each of the disorders and conditions listed in your DSM-5.
The Greater Specificity of ICD-10 Codes
Is an Important Improvement
Even apart from the boldface text, parentheses, and codes that begin with “F,” the DSM-5, ICD-9-CM, and ICD-10 codes are easily distinguishable. ICD-9-CM codes comprise three to five digits. ICD-10 will be three to seven digits long, which will broaden the number of codes clinicians can use. And that’s significant.
With the ICD-10, CMHCs will be able to code with much greater specificity the condition they are treating. For example:
- In medicine, because of the limited number of code numbers that can be used in the ICD-9-CM, a clinician can’t code which side of the body is injured. In the ICD-10, however, the injured side of the body can be indicated.
- For anorexia, the ICD-9-CM had only one code number available. There was no way to code the subtypes, such as whether the anorexia was the restricting type or the binge-eating/purging type. Codes in the ICD-10 though, make this distinction.
- For ADHD, in the ICD-9-CM, only two subtype codes are available though there are three types of ADHD identified in the DSM-5 (hyperactive, inattentive, or combined type). In the ICD-10, all three subtypes can be coded.
- In ICD-9, if a person has substance dependence and, say, an induced condition like psychosis from the alcohol use, the two conditions would be coded separately. The expanded ICD-10 codes provide a way to use one code number to code both the dependence as well as the induced condition associated with it.
How Well Do the DSM and ICD Match?
The DSM and ICD are like two similar but different languages. The code number that is used in the DSM reflects the closest approximation to the condition in the ICD. … Sometimes.
Sometimes the diagnosis and code are a very
Tap These Resources to Prepare for the Shift to
the ICD-10 on Oct. 1
- AMHCA PRE-CONFERENCE WORKSHOP:“Applied Clinical Synthesis: Integrating the DSM-5 with the Affordable Care Act (ACA),” is a full-day workshop offered by Jason King, PhD, NCC, ACS, DCMHS in two parts, and presented on July 10, in Seattle, immediately prior to AMHCA’s Annual Conference, July 10–12. The implementation of DSM-5 and ICD-10 represents a fundamental shift in how health disorders are conceptualized and diagnosed. King’s workshop will review the changes to the major psychiatric diagnostic groups, and participants will have an opportunity to practice using the new system with applied clinical examples. For more information, see the Annual Conference article in this issue.
- BOOK:A very good source that discusses the ICD-10 and mental and behavioral disorders is, “A Primer for ICD-10-CM Users: Psychological and Behavioral Conditions,”a recent book by psychologist and 2010 American Psychological Association President Carol D. Goodheart, EdD. Published by APA Press, the book provides a nice overview of the ICD-10 and its relationship to the DSM-5. It’s probably the single best thing out there for mental health clinicians.
- WEBINAR: Goodheart offers a for-pay webinar through the Clinician’s Corner section of the American Psychological Association website, a three-hour presentation (3 CE credits / $65).
- TWO WORKSHOPS by Gary Gintner, PhD:
good match; other times they are not. Though the disorders in the DSM and the ICD match fairly well in many places, they don’t match perfectly.
For example, binge-eating disorder in the DSM-5 maps to bulimia in both ICD-9 and ICD-10. That’s not a very good match because binge-eating doesn’t include compensatory behaviors like purging.
Likewise, hoarding disorder, a new disorder in the DSM-5, maps to OCD in both ICD-9 and ICD-10. They’re related but differ in important ways—that’s why DSM-5 differentiates them. The same goes for brand new DSM-5 disorders such as disruptive mood dysregulation disorder, which is not yet in the ICD-10. In the ICD-10, that maps closest to “other persistent mood disorders.”
The concept of spectrum disorders, an innovation of DSM-5, is not reflected in ICD-10 terminology. Remember, ICD-10 is essentially a product of the early 1990s. But because the ICD code numbers are revised annually, there is a chance that new code numbers will be added that will more closely mirror these new DSM-5 disorders.
Since ICD-10 was developed in 1992, though the United States elected not to adopt it until this fall, it’s been around now for 20 years, and so the release of ICD-11 is just around the corner. Expected to be released in 2015, ICD-11 is going to be a major improvement over ICD-10 since it will match the DSM-5 even more closely. ICD-11 will also include a lot of chapter titles that are similar to the DSM-5 chapter titles, such as “Neurodevelopmental Disorders,” “Bipolar and Depressive Disorders,” and “Neurocognitive Disorders.”
Until the ICD-11 arrives, the ICD is being used mainly as a statistical manual—clinicians use it to report codes associated with a mental disorder. Though there is a version of ICD-10-CM that includes diagnostic criteria, “Clinical Descriptions and Diagnostic Guidelines,” it is not widely disseminated nor recommended for use, according to “Primer for ICD-10-CM Users,” by Carol D. Goodheart, EdD (2014). Referred to as the “blue book,” clinicians will find the criteria simplified and the background information minimal, by DSM standards. However, ICD-11 is planning a companion “Clinical Descriptions” manual that may prove more useful—time will tell.
Another version of the ICD, “ICD-10 Classification of Mental and Behavioral Disorder: Diagnostic Criteria for Research,” is used as a reference for researchers. The criteria are much more specific than the “Clinical Descriptions” described above and more closely approximates the detail in the DSM criteria.
When the DSM-5 came out in 2013, it generated a lot of discussion and criticism, but the ICD-11 has flown under the radar so far. Possibly that’s because clinicians don’t use the ICD to diagnose. If substantial clinical descriptions are released with the ICD-11, they deserve the same level of scrutiny given to the DSM-5.
Don’t Be Intimidated!
After Oct. 1, just use the code numbers in the DSM-5 that are in parentheses and usually start with the letter “F.” The way you narratively write out the diagnosis does not change. Each version of the DSM has had ICD codes that have been matched as closely as possible to similar ICD terms for those codes, so this is nothing really different. My take on it all is that the ICD is used to report a diagnostic code, while the DSM is used to diagnose the condition at hand with its greater attention to specific criteria and diagnostic information.
Remember that what you’re treating is not a code number; you’re treating a client, and you’re using the DSM to develop a descriptive diagnosis that informs your overall case formulation.
Gary G. Gintner chaired AMHCA’s DSM-5 Task Force. He is also a member of the World Health Organization Global Clinical Practice Network, conducting field trials on the ICD-11. An associate professor and program leader in Counselor Education at Louisiana State University, Gintner has presented workshops around the country on the DSM-5 and is a past president of AMHCA.