ICD-10 Changes

I know it's been forever. I have actually been super busy. I still am, but since this is timely and important, I thought I'd post something.

There are ICD-10 changes that go into effect on October 1st. These are intended to correspond to recent changes in DSM-5. I suppose it should now be called DSM-5.1.

These are the changes:

I hope this is helpful.

My ICD-10 Bad

I recently posted about ICD-10, with a link and a widget and whatnot. Most of what I posted is still valid, as far as I know. But I got a message today from the same friend and colleague who sent me the original link, about an email she received from the state:

Claims should not contain both ICD-9 codes and ICD-10 codes. Claims that are billed with both ICD-9 and ICD-10 diagnosis codes on the same claim may also be considered unprocessable. Therefore, services rendered prior to October 1, 2015 should be billed separately than services rendered from October 1, 2015 forward.

So I'm going to take the ICD-10 diagnoses off my September bills, and the ICD-9 diagnoses off the October bills. I'm guessing the insurance companies will be confused, but at least they won't be able to say I didn't do what they asked.

Remember: 9 through 9 (September), and 10 starts in 10 (October).

And big thanks to Susan.

ICD-10, Comin' At Ya

A friend and colleague sent me a little present-a link to an online ICD-9 to ICD-10 converter.

The site is AAPC.com, and I couldn't figure out what, exactly, AAPC stands for, but as far as I can tell, it's something like, American Association of Professional Coders, and it offers training and certification in medical coding and billing, among other things.

The above link also has a countdown timer to October 1st, when ICD-10 coding will be required.

I've posted previously about ICD-10, (and there's still the page link up at the top of my blog with common diagnoses conversions). There seems to be a lot of fuss about the conversion, but I don't think it's going to be that big a deal in psychiatry. I think there is a much more manageable number of codes than in, say, internal medicine, so I'm not too concerned. What I've been doing about it, lately, is starting to include ICD-10 coding in my charts, and on this month's bill. But I'm also retaining the ICD-9 coding on the bill, for the time being, because I think it's going to be a while before the insurance companies get things figured out, and with both codes, they don't have an excuse not to reimburse.

So my bills say something like:

Dx: ICD-9  296.30; ICD-10  F33.9

Hopefully, that'll work out okay.

Incidentally, what I mean by including ICD-10 coding in my charts is that I handwrite the ICD-10 code on the inside of a patient's folder, i.e. physical chart, right under where I've handwritten the ICD-9 code. Sometimes low-tech is a good thing.

I asked the friend who sent me the link if I could post it, and she, in turn, asked the person who sent her the link, who wrote back that I could post it, and who wished to have her information listed in this form:

Rachel T. Greenwald, Ph.D. of RTG Billing, telephone (347) 980-2417 and email rachel@rtgbilling.com.

I'm trying not to do anything shady in this, but it seems to be a free site, open to the public, and it was a nice gesture. So I hope that turns out okay, too.

And in case you haven't noticed, I put an ICD-9 to ICD-10 converter widget, which I got from the AAPC site, at the top of the column to the right. I tried it out, and it takes you to the site, rather than just giving you the code right in the widget, so I may take it down at some point. But right now, with the conversion imminent, I consider it a public service.

Addendum:

See also, My ICD-10 Bad for a correction.

ICD-10 List

Am I missing something about ICD-10? There's a whole lot of fuss about preparing for the transition and testing of systems to see if they comply with the transition. Don't you just need to use a different code? I guess it's more complicated in something like orthopedic surgery, where there's a lot more specificity you can get with ICD-10. And if you use an EMR or some kind of billing system, it needs to generate the new codes. See how it's so much easier not to use an EMR?


Here's a link to ICD-10 Basics. It includes a "Build Your Action Plan" link. I tried it out. It asked for my specialty (Other), how many physicians in my practice (1-2), what technology I used (EHR, which includes ERx), What type of insurance I take (none), and what stage of ICD-10 readiness I'm at (planning).

It gave me this:

Out of curiosity, I tried it again with Orthopedics, 3-6 physicians, EMR/Billing System, Commercial insurance and medicare, and planning stage. It gave me the exact same action plan.


Well, anyway, in preparation for the switch to the ICD-10 coding system this October, or maybe the following one, or the one after that, or some time in the next decade, I decided to smooth the transition for myself by making a list of my most frequently used ICD-9 codes, and converting them to ICD-10 codes via the ICD-9 Diagnosis Converter, which I mentioned in a previous post.

A couple of brief notes:

Only HIPAA covered entities are required to comply with mandatory ICD-10 coding. I'm not a HIPAA covered entity, but I'm going to do it anyway, since it will probably confuse insurance companies if I don't. Or maybe that won't matter because no one will have out of network mental health insurance.

There are two coding systems-ICD-10-CM, and ICD-10-PCS. The difference is that the PCS system is only for inpatient coding.

I currently don't use DSM codes, just ICD-9 ones, so you may need to adjust accordingly. I do this mainly as a form of protest, but also because the ICD system allows for more flexibility in terms of the types of patients I treat. For example, ICD-9 300.4 is Dysthymia, which is the same in DSM. But in ICD-9, Dysthymia includes things like "Depression with Anxiety" and "Neurotic Depressive State"-all billable.

The other point I want to make is that if you have access to DSM-5, you'll notice it includes ICD-10 codes. But I still thought that, at least for myself, it would be helpful to have a simple list of my most commonly used diagnoses, But I also thought I'd add a few more codes that I don't see very frequently, but might be helpful to others.

Finally, it's interesting to note that there's not a direct 1:1 correspondence between DSM-5 diagnoses and ICD-10 diagnoses, and a lot of times, you have to make your best guess. I"m not sure where that leaves DSM-5 in terms of how definitive it believes its diagnoses are.

So, here goes.

In ICD-10, Mental, Developmental, and Neurodevelopmental disorders are coded with an "F" as a prefix, from F01-F99. This is in contrast with Diseases of the Nervous System, which have the prefix, "G". And again, I wonder what implications this distinction has more generally.

There are 10 different sections, from "Mental disorders due to known physiological conditions" to 'Behavioral and emotional disorders with onset usually occurring in childhood and adolescence", plus F99, the meta-vague "Unspecified Mental Disorder".


I'll start with Depressive d/o's:

Note the difference from ICD-9, where the equivalent severity specifiers run from 1 to 4, rather than 0 to 3.

Also note that ICD Dysthymia is different from DSM Dysthymia. It includes the DSM version of Dysthymia, but it extends it:

Clinical Information

• A term used for any state of depression that is not psychotic
• Chronic affective disorder characterized by either relatively mild depressive symptoms or marked loss of pleasure in usual activities
• Chronically depressed mood that occurs for most of the day more days than not for at least 2 years. The required minimum duration in children to make this diagnosis is 1 year. During periods of depressed mood, at least 2 of the following additional symptoms are present: poor appetite or overeating, insomnia or hypersomnia, low energy or fatigue, low self esteem, poor concentration or difficulty making decisions, and feelings of hopelessness. (dsm-iv)
• Depression precipitated by events in a person's life

Applies To

• Anxiety depression
• Depression with anxiety
• Depressive reaction
• Neurotic depressive state
• Reactive depression

Disease Synonyms

• Anxiety associated w depression
• Anxiety depression
• Anxiety with depression
• Depression, reactive
• Dysthymia
• Mixed anxiety and depressive disorder
• Reactive depression
• Reactive depression (situational)

For the purposes of my practice, this is a really useful diagnostic category, because there's a lot of leeway for depressive symptoms.


Bipolar d/o's:

ICD-10 has a separate heading for Manic Episodes and bipolar D/O.

This is a little fiddly, but Bipolar D/O excludes
* bipolar disorder, single manic episode
* major depressive disorder, single episode
* major depressive disorder, recurrent
* cyclothymia

But it includes
* manic-depressive illness
* manic-depressive psychosis
* manic-depressive reaction

Manic Episode without Psychotic sx is F30.1x,
where x = 0 for unspecifed, 1 for mild, two for moderate, and 3 for moderate without psychotic sx.

This differs from the severity specifiers listed above for MDD.

However, Manic Episode, severe, with psychotic sx has its own code, F30.2

Furthermore, Cyclothymia has a completely separate code, F34.0, and it includes:

* Affective personality disorder
* Cycloid personality
* Cyclothymia, and
* Cyclothymic personality

And more:

Note: Other specified PDD is Asperger's in ICD-10.

And finally, since there are so many different types of substances of abuse, I'm only including Alcohol:

In general, I don't think it matters much what number you put down, except for billing purposes. But it's clear that the ICD system thinks about mental disorders somewhat differently than the DSM does.


Here's a little comic relief to end with. There are some ICD-9  codes that have the same letters and numbers (sometimes with changes in decimal places) as some ICD-10  codes, but mean completely different things. For example,

ICD-9  E802.0 = Railway accident involving derailment without antecedent collision injuring railway employee

ICD-10  E80.20 = Unspecified Porphyria

And finally, finally, if you check the top of the blog, you'll see I've added an additional page, right next to, "Disclaimers," entitled, "ICD-9 to ICD-10 Transition," which is the entire table in one place, albeit a little wonkily, for future reference.

Free Diagnostic Coding Reference-Yay!

This is so great!

You have to check out this ICD coding reference.

These techno-angels have created a free database of ICD-9 codes, including those for 2013.

We've taken the official 2006-2013 ICD-9-CM and HCPCS coding books and added 5.3+ million hyperlinks between codes. Combine that with a Google-powered search engine, drill-down navigation system and instant coding notes  and it's easier than ever to quickly find the medical coding information you need.

They're supported by Google Adsense, so it's totally free to use. The'll even convert ICD-9 codes to ICD-10 codes. And they were happy to have me link to their site. You gotta love these guys.

What would be super-great is if they wrote some code to convert DSM-IV codes to ICD-9 codes. Maybe I'll write to them about it.

And for future reference, I've added a link to their site under "Useful Links", to the right.

WHO-Hoo!

Here's some good news for anyone who doesn't want to buy, read,
or use the DSM-5.

The World Health Organizatio (WHO) provides free online ICD-10 access, and free online ICD-10 training. I worked through most of the training, and it's a bit dull, but pretty intuitive.

Fittingly, Mental and Behavioral Disorders are in chapter V.

Here's a peak at how depression is described, ICD-10 style:

Depressive episode

In typical mild, moderate, or severe depressive episodes, the patient suffers from lowering of mood, reduction of energy, and decrease in activity. Capacity for enjoyment, interest, and concentration is reduced, and marked tiredness after even minimum effort is common. Sleep is usually disturbed and appetite diminished. Self-esteem and self-confidence are almost always reduced and, even in the mild form, some ideas of guilt or worthlessness are often present. The lowered mood varies little from day to day, is unresponsive to circumstances and may be accompanied by so-called "somatic" symptoms, such as loss of interest and pleasurable feelings, waking in the morning several hours before the usual time, depression worst in the morning, marked psychomotor retardation, agitation, loss of appetite, weight loss, and loss of libido. Depending upon the number and severity of the symptoms, a depressive episode may be specified as mild, moderate or severe.

Incl.:

single episodes of:

• depressive reaction
• psychogenic depression
• reactive depression

Excl.:

adjustment disorder (F43.2)

recurrent depressive disorder (F33.-)

when associated with conduct disorders in F91.- (F92.0)

F32.0Mild depressive episode

Two or three of the above symptoms are usually present. The patient is usually distressed by these but will probably be able to continue with most activities.

F32.1Moderate depressive episode

Four or more of the above symptoms are usually present and the patient is likely to have great difficulty in continuing with ordinary activities.

F32.2Severe depressive episode without psychotic symptoms

An episode of depression in which several of the above symptoms are marked and distressing, typically loss of self-esteem and ideas of worthlessness or guilt. Suicidal thoughts and acts are common and a number of "somatic" symptoms are usually present.

Agitated depression Major depression Vital depression

single episode without psychotic symptoms

Who-Hoo! No more Chinese menu!

ICD-10 codes are very different from ICD-9 codes, which are structured like DSM codes. Will insurance companies accept them? Looks like they will, starting October 1, 2014. Until then, ICD-9 will have to do.

Thanks, WHO.