DSM-IV-TR to ICD-9-CM: An Uneven Path

By Kevin B. Shields, CPC, CCP, CCS-P, CPC-P, RCC, ACP
With the 2005 disappearance of Appendix B (Glossary of Mental Disorders) from ICD-9-CM, some coders have been left adrift to maneuver the somewhat confusing task of assigning appropriate diagnostic codes for mental health services. This abandoned tool was sometimes the clarifying factor in code assignment. The glossary also afforded coders the opportunity to easily locate (non-reportable) associated signs and symptoms for this set of codes. Indeed, it remains a tool missed by many. Despite its absence, coders have the DSM-IVTR (Diagnostic & Statistical Manual of Mental Disorders, 4th Edition, Text Revision) as a detailed replacement for the glossary. Although DSM-IV-TR is primarily aimed at clinicians, it may still be of importance to the coding professional. In the past few years, the alphabetic and tabular indexes of ICD-9-CM have been modified slightly to more accurately reflect the DSM-IV-TR lexicon. This clinical tool should not supplant ICD-9-CM.

A Little History

The U.S. Census can be credited with the humble beginnings of a DSM format. In 1840, a single category for mental illness was created, “idiocy/ insanity.” In the 1880’s Census, that was expanded to seven categories. Between 1880 and World War II, a number of professional mental health organizations devoted effort to a more sound, clinically reflective classification system. However, it was the inception of ICD-6 by the World Health Organization (WHO) — which, for the first time included a chapter devoted to mental disorders — that we can identify as the apparatus for our current day DSM-IV-TR.
At the inception of ICD, the APA developed DSM to provide the depth and description of psychiatric illnesses that ICD did not. Of note, the Veterans Administration greatly influenced the language of ICD-6 and its categorization. DSM-I came about in 1952 as an American Psychiatric Association Committee on Nomenclature and Statistics’ adaptation of ICD-6.
This is a relatively brief overview of the origins of DSM-IV-TR, its tie to ICD-9-CM, and virtual arrival to the existing systems we employ. For coding professionals to properly code from the mental disorders section of ICD-9-CM, they must first understand the manner in which documented conditions are listed. This is referred to as the multiaxial system. There are five axes, each one including specific aspects affecting a patient’s mental or overall health.
Axis I: Clinical Disorders and Other Conditions That May be a Focus of Attention (includes anypsychiatric disorder, excluding personality disorders and mental retardation).
Axis II: Personality Disorders and Mental Retardation.
Axis III: General Medical Conditions
Axis IV: Clinically Relevant psychosocial/ environmental problems.
Axis V: Global Assessment of Functioning (overall psychological, social and occupational functioning).
As coders, we can use the DSM-IV-TR to help us understand the language that is particular to mental health clinicians. The typical manifestations of a particular mental disorder are indicated by searching for the disorder (via the Index, DSM-IV-TR Classification page or the Contents) and reading the Associated Features or Diagnostic Criteria related to that particular disease.
Example: The clinician notes, “Axis I: ETOH Withdrawal, DTs, Axis II: deferred, Axis III: auditory/visual hallucinations, Axis IV: current divorce, legal difficulties (DUI, assault charges), housing issues, Axis V: 75.”
Let’s say we want to know if the documented auditory and visual hallucinations should be additionally reported. By searching DSM-IV-TR’s index, we encounter “substance withdrawal.” From there we narrow the field to the one particular to our “alcohol withdrawal” diagnosis. Under the Diagnostic Criteria for Alcohol Withdrawal, it mentions, “transient visual, tactile, or auditory hallucinations or illusions.” Therefore, we can establish that those features mentioned on Axis III are included in our code for alcohol withdrawal.
A bit more work is involved compared to the Glossary of Mental Disorders in our older version of ICD-9-CM, which clearly stated that the hallucinations were included under the delirium tremens listing. Although our glossary has gone the way of our older books, the information is still available to us. An important side note is that the multiaxial system does not translate to diagnostic ordering. In other words, it is imperative that coders still make use of and pay mind to the ICD-9-CM Official Guidelines for Coding and Reporting, as those will set the precedence of code order.
This is especially true in cases in which a mental health clinician treats those disorders arising from a general medical condition. ICD-9-CM rules should not be violated, should be reviewed in accordance with each case, and utilized to determine the principal (or “first listed”) diagnosis. Occasionally, ICD-9-CM and DSM-IV-TR seem to disagree. However, with due diligence, a reportable diagnosis code can be uncovered using both systems as coding guides for the mental disorders chapter of ICD-9-CM.
At times like these, AHA Coding Clinic may resolve any presumed discrepancies. In several Federal Registers, CMS has recognized discrepancies between the systems, always pointing out that the final rule of Standards for Electronic Transaction recognizes ICD-9-CM as the official reporting system. As usual, it becomes the coder’s duty to ensure appropriate representation in that system. Thankfully, DSM-IV-TR is compatible with the language we will use upon the implementation of ICD-10-CM. Although problems may arise, it is encouraging to know that language built into ICD-10-CM mimics the current style in the DSM-IV- TR. As we look into the future this provides one less concern we should have in adopting the newer classification system.

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