ICD-10-CM Psychological and Behavioral Disorders
Regulatory Requirements and
Relationship to Clinical Use of DSM-5 Diagnostic Criteria
Scott D. Daubert, Ph.D.
VP, Operations
• Overview, introduction and history of ICD-10.
• The ICD-10-CM.
• Differences between ICD-9-CM and ICD-10-CM structures.
• Framework of the ICD-10-CM.
• Clinical descriptions and diagnostic guidelines:
DSM-IV-TR and DSM-5.
WHO guidelines.
• Preview of ICD-11.
ICD-9 History and Overview
• The World Health Organization (WHO) developed ICD-9
for use worldwide:
Global, cooperative statistical effort to report and improve public health.
The U.S. developed “clinical modification” (ICD-9-CM).
Implemented in 1979 in the U.S.
Expanded number of diagnosis codes.
Developed procedure coding system.
• ICD-9-CM diagnoses — used by all types of providers.
• ICD-9-CM procedures — used only by inpatient hospitals.
• Impact for PerformCare is limited to diagnoses.
ICD-9 History and Overview
• What is ICD-9-CM used for?
Calculate payment — Medicare Severity-Diagnosis Related Groups (MS-DRGs).
Adjudicate coverage — Diagnosis codes for all settings.
Compile statistics — Original reason for WHO global standards.
Assess quality — Diagnoses is a important component of directing treatment.
• ICD-9-CM is outdated:
30 years old — Technology has changed.
Many categories full.
Not descriptive enough, not intuitive in organization.
• What characteristics are needed in a coding system?
Flexible enough to quickly incorporate emerging diagnoses and procedures.
Exact enough to identify diagnoses and procedures precisely.
ICD-9-CM is neither of these.
ICD-10 History and Overview
• 1990 — Endorsed by World Health Assembly (diagnosis only).
• 1994 — Release of full ICD-10 by WHO.
• 2002 (October) — ICD-10 published in 42 languages (including
six official WHO languages).
• Implementation:
138 countries for mortality.
99 countries for morbidity.
January 1, 1999 — U.S. implemented for mortality (death certificates).
• 95% of the world’s health professionals already use ICD-10.
Countries Using ICD-10 For Reimbursement or Case Mix
• United Kingdom (1995)
• Nordic countries (Denmark, Finland, Iceland, Norway, Sweden)
(1994 – 1997)
• France (1997)
• Australia (1998)
• Belgium (1999)
• Germany (2000)
• Canada (2001)
Structural Differences — ICD-9-CM Diagnoses
• ICD-9-CM has three to five digits.
• Chapters 1 – 17: All characters are numeric.
• Supplemental chapters: First digit is alpha (E or V), remainder are
• Examples:
311 — Depressive disorder not elsewhere classified.
296.32 — Major depressive affective disorder recurrent episode
moderate degree.
V61.20 — Counseling for parent-child problem unspecified.
Structural Differences ICD-10-CM Diagnoses
• ICD-10-CM has three to seven digits:
Digit 1 is alpha (A – Z, not case sensitive).
Digit 2 is numeric.
Digit 3 is alpha (not case sensitive) or numeric.
Digits 4 – 7 are alpha (not case sensitive) or numeric.
If there is a decimal, it is always after the 3rd character.
ICD-9-CM has 14,025 codes, while ICD-10-CM has 68,069 codes.
• Examples:
2014 ICD-10-CM Code
2014 ICD-10-CM Description
Mild intellectual disabilities.
Bipolar disorder, current episode manic
severe with psychotic features.
Paranoid schizophrenia.
DSM-5 Description
Intellectual disability (intellectual
developmental disorder), mild.
Bipolar I disorder, current or most recent
episode manic, with psychotic features.
ICD-9-CM Code
Schizophrenia, unspecified.
Opioid dependence with intoxication
Opioid Intoxication delirium, with moderate or
severe use disorder.
Framework of the ICD-10-CM
• 21 chapters in the list of diseases and injuries:
Chapter 1 — Certain infectious and parasitic diseases (A00 ‒ B99).
Chapter 2 — Neoplasms (C00 ‒ D49).
Chapter 3 — Disease of the blood and blood-forming organs and certain
disorders involving the immune mechanism (D50 ‒ D89).
Chapter 4 — Endocrine, nutritional and metabolic diseases (E00 ‒ E89).
Chapter 5 — Mental, behavioral and neurodevelopmental disorders (F01 – F99).
Continues to Chapter 21…
• All of the mental and behavioral disorder codes begin
with the letter F.
Although there is room for up to seven characters, most of the BH disorders
have four or five total characters.
Pause for Questions
Framework within Chapter 5, Behavioral Health, F codes
ICD-10-CM Code Range
F01 ‒ F09
Mental disorders due to known physiological conditions.
F10 ‒ F19
Mental and behavioral disorders due to psychoactive
substance abuse.
F20 ‒ F29
Schizophrenia, schizotypal, delusional, and other non-mood
psychotic disorders.
F30 ‒ F39
Mood (affective) disorders.
F40 ‒ F48
Anxiety, dissociative, stress-related, somatoform, and other
non-psychotic mental disorders.
F50 ‒ F59
Behavioral syndromes associated with physiological disturbances
and physical factors.
F60 ‒ F69
Disorders of adult personality and behavior.
F70 ‒ F79
Intellectual disabilities.
F80 ‒ F89
Pervasive and specific developmental disabilities.
F90 ‒ F98
Behavioral and emotional disorders with onset usually occurring
in childhood or adolescence.
Unspecified mental disorder.
Clinical Descriptions and Diagnostic Guidelines (DSM-IV and DSM-5)
• As of Oct. 1, 2014, the ICD-10-CM code set is the HIPAA-adopted
standard, and required for reporting diagnosis for dates of service
on or after Oct. 1, 2014. (Delayed again until Oct. 1, 2015.)
• Neither the DSM-IV nor DSM-5 is a HIPAA-adopted code set, and
may not be used in HIPAA standard transactions (e.g., claims).
• DSM-5 is “compatible” with both ICD-9-CM and ICD-10-CM.
The DSM-5 manual provides a crosswalk to both sets of codes.
• There is no published (APA) DSM-IV direct crosswalk to
• The Oct. 1, 2015, date does not mandate clinical use, but such
use must be translated to ICD-10-CM as of that date.
An Example of a Crosswalk Discrepancy
A case of agoraphobia with panic disorder:
• DSM-5 diagnosis of agoraphobia.
ICD-10-CM crosswalk = F40.00, Agoraphobia, unspecified.
• DSM-5 diagnosis of panic disorder.
ICD-10-CM crosswalk = F41.0, Panic disorder [episodic paroxysmal anxiety]
without agoraphobia.
• There is no DSM-5 category that combines agoraphobia with
panic disorder.
• In ICD-10-CM, F40.01 = Agoraphobia with panic disorder.
ICD-11 and the WHO CDDG
• Clinicians need guidance for making diagnoses beyond
just having a code set.
This has been the role of the DSM publications, but only in the United States.
• The Blue Book, published by the WHO (1992):
The ICD-10 Classification of Mental and Behavioral Disorders: Clinical
Descriptions and Diagnostic Guidelines (CDDG).
Explicitly removed from use in the United States.
Not part of ICD-10-CM.
The CDDG is being updated for ICD-11.
WHO adoption of ICD-11 is scheduled for 2015.
• WHO opinion of DSM-5:
The definition of disease “cannot be legitimately managed by a single
professional organization representing a single health discipline in a single
country with a substantial commercial investment in its products.”
Goodheart, Carol D. (2014) A Primer for ICD-10-CM Users.
• Dates of service on or after October 1, 2015.
• F Codes = Behavioral health.
• Further subdivision of F Codes 01 ‒ 99.
• Minor incompatibilities between DSM-5 and ICD-10-CM.
• Many more diagnostic options in ICD-10-CM.
• Not all DSM-5 diagnoses are F category, or behavioral health.
• PerformCare next steps:
Issuance of provider notice and crosswalk.
IS system upgrades.
Testing with trading partners.
Web Resources
• General ICD-10 information (including regulations)
• General ICD-10 information and mapping
• General ICD-10 information and FFS implementation
Contact presenter with additional questions:
Scott Daubert, Ph.D.
VP, Operations
[email protected]

similar documents