Rise to Psychiatry Coding Challenges
When following DSM-5 to ICD-10 crosswalk recommendations, look out for dead ends.
The introduction of Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) to the psychiatric community brought with it new challenges for the coder. With its predecessor, DSM-IV, we enjoyed a relative harmony with ICD-9-CM, but ICD-9-CM is on its way out, soon to be replaced by ICD-10-CM.
During development of DSM-5, there became an awareness that DSM-IV and ICD-10-CM diagnoses do not always agree. Although DSM-5 includes the American Psychiatric Association’s crosswalk from DSM-5 to ICD-9-CM and ICD-10-CM, crosswalk recommendations do not always lead to the codes we’re used to seeing when following ICD-9-CM guidelines.
Significant Changes from DSM-IV to DSM-5
To use DSM-5 for proper code assignment, be aware of how it differs from DSM-IV. Here’s a run-down:
- The multi-axis system (I-V) introduced with DSM-III has been eliminated. Coding would regularly use the first three axes for diagnoses:
- Axis I: Mental and clinical disorders
- Axis II: Personality and clinical disorders
- Axis III: Physical problems that may be relevant to the diagnosis and treatment of mental disorders
DSM-V combines all three axes into a single list that contains mental and personality disorders, intellectual disabilities, and other medical diagnoses.
Tip: Frequently, physician documentation notes the designated “active problem list” with no primary diagnosis indicated. If the documentation does not clearly support a primary diagnosis (reason for encounter), query the provider for clarification.
- Not otherwise specified (NOS) has been replaced with “other disorder” or “unspecified disorder.”
- DSM-IV listed 22 codes as the ICD-9-CM factors influencing health status, while DSM-5 lists 88 codes.
- Codes describing abuse increase from five to 44.
- There are 17 new disorders, 28 nomenclature changes, and 14 new combination codes.
- The words “probably” (17X) and “possible” (4X) have been added to the name of some neurocognitive disorders. These are non-existent in DSM-IV and ICD-9-CM.
- Severity scales (e.g., mild, moderate, severe) have been added to many codes.
Crosswalked Codes Reveal Inconsistencies
Nomenclature changes and new disorders represent the most significant challenge to the psychiatry coder. Not only are they not found in the ICD-9-CM indices, but the “crosswalk” codes provided in DSM-5 do not always reflect the actual code arrived at through established coding guidelines. There is a host of diagnoses that were replaced with new codes or combined into a single code. Some major changes in DSM-5, as compared to ICD-9-CM, include:
- Autism spectrum disorder (299.00 Autistic disorder, current or active state) eliminates pervasive development disorder (299.90 Unspecified pervasive developmental disorder, current or active state) and Asperger’s syndrome (299.80 Other specified pervasive developmental disorders, current or active state).
- Somatic symptom disorder (300.82 Undifferentiated somatoform disorder) replaces somatization (300.81 Somatization disorder and 306.9 Unspecified psychophysiological malfunction) and somatoform disorder (300.82).
- Major neurocognitive disorder (294.XX) with a separate code for “possible” (331.83 Mild cognitive impairment, so stated, 331.9 Cerebral degeneration, unspecified), dementia.
- Social (pragmatic) communication disorder—new (315.39 Other developmental speech or language disorder)
- Language disorder (315.39) no longer differentiates expressive language disorder (315.31 Expressive language disorder) and mixed receptive expressive language disorder (315.32 Mixed receptive-expressive language disorder).
- Catatonic, disorganized, paranoid, residual, and undifferentiated schizophrenia are replaced with schizophrenia (205.9X).
- Social anxiety disorder (listed as 300.23 Social phobia in DSM-5, but codes to 300.09 Other anxiety states ICD-9-CM) replaces social phobia, which codes to 300.23.
- Binge eating disorder (307.51 Bulimia nervosa) codes to eating disorder (307.59 Other disorders of eating) in ICD-9, and changes from binge-purge syndrome (307.51)—not listed in ICD-9-CM or ICD-10-CM.
- Drug/Alcohol abuse (305.90 Other, mixed, or unspecified drug abuse, unspecified and 305.00 Alcohol abuse, unspecified) are now referred to as addictions (304.80 Combinations of drug dependence excluding opioid type drug, unspecified and 303.90 Other and unspecified alcohol dependence, unspecified)
- Disruptive mood dysregulation (296.99 Other specified episodic mood disorder), new, is not listed in ICD-9-CM or ICD-10-CM.
- Social communication disorder (315.39 Other developmental speech or language disorder), new, is not listed in ICD-9-CM or ICD-10-CM.
- Disinhibited social engagement (313.89 Other emotional disturbances of childhood or adolescence), new
- Panic disorder without agoraphobia (300.1 Dissociative, conversion and factitious disorders) and panic disorder with agoraphobia (300.21 Agoraphobia with panic disorder) are now coded to 300.01 Panic disorder without agoraphobia. DSM-5 lists panic disorder as recurrent unexpected Panic attacks 300.01. It separately lists agoraphobia as 300.22 Agoraphobia without mention of panic attacks. If both are present, you need to use both codes.
- Hoarding (300.3 Obsessive-compulsive disorders), new, is not listed in ICD-9-CM or ICD-10-CM.
- Excoriation/Skin picking (698.4 Dermatitis factitia [artefacta) is dermatitis factitia (neurotic excoriation) in ICD-9-CM and is instructed to use a code for any associated mental disorders. If “unspecified excoriation or other specified” is selected, it will code to 919.8 Other and unspecified superficial injury of other, multiple, and unspecified sites, without mention of infection.
- Provisional tic disorder (307.21 Transient tic disorder) provisional nomenclature replaces transient tic disorder (307.21).
- Persistent depressive disorder (300.4 Dysthymic disorder) replaces dysthymia in DSM-5.
One of the most significant changes is the classification of personality disorders. These are now divided into Cluster A (301.0, 301.20, 301.22), B (301.7, 301.83, 301.50, 301.81), C (301.82, 301.6, 301.4), or “Other.” If the specific personality disorder is not documented, communication with the provider is vital to selecting an accurate code.
DSM vs. ICD
The challenge lies in whether to code the physician’s diagnosis using DSM-5 nomenclature as referenced, which does not translate to the same code in ICD-9-CM, or to select a code from ICD-9-CM and, in doing so, ignore the clear intent of the physician’s documentation. If you do the former, you are coding from DSM-5. If you do the latter, you run the risk of assigning a code that doesn’t accurately reflect the diagnosis assigned by the provider.
To help you accurately represent the patient’s diagnoses, it’s vital to consider psychiatric coding challenges and answer reporting questions. Demonstrate good communication with your provider during the transition to ICD-10-CM to ensure the patient’s diagnoses accurately reflect his or her state of health.
J.C. Cortese, MS, DC, CPC, has worked for the University of Iowa Hospital and Clinics, Department of Psychiatry, Coding Intelligence Division since 2012. She has a Doctor of Chiropractic degree from Northwestern Health Sciences University and a Master of Science from Vanderbilt University. After retiring from chiropractic practice, Cortese spent 12 years translating orthopedic research from Czech to English at Motol Hospital, First Faculty of Orthopedics, Prague, Czech Republic.
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