Disclaimer

The information contained in this extended presentation is not intended to The Changing Face of Healthcare: reflect AMA, APA, CMS (Medicare), any division of APA, NAN, NAP, NCPA (or any state psychological association), state Medicaid and/or any private third The Interface Between CPT & ICD party carrier policy. Further, this information is intended to be informative and does not supersede APA or state/provincial licensing boards’ ethical guidelines and/or local, state, provincial or national regulations and/or laws. Further, Local Coverage Determination and specific health care contracts supersede the information presented. The information contained herein is meant to provide practitioners as well as health care institutions (e.g., insurance companies) involved in psychological services with the latest ANTONIO E. PUENTE information available to the author regarding the issues addressed. This is a living document that can and will be revised as additional information UNIVERSITY OF NORTH CAROLINA WILMINGTON becomes available. The ultimate responsibility of the validity, utility and application of the information contained herein lies with the individual and/or institution using this information and not with any supporting organization and/or the author of this presentation. Suggestions or changes should be directly addressed to the author. Note that whenever possible, references are provided. Finally, note that the CPT system is copyrighted and the information contained should be treated as such. CPT information is provided as a source of education to the readers of the materials contained. Thank you…aep

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Acknowledgments: Acknowledgments: Individuals Organizations  North Carolina Psychological Association (NCPA) • AMA: Marie Mindenman, Tracy Gordy, Peter  American Psychological Association (APA) Practice Hollman Directorate (PD); Ethics Committee  American Medical Association (AMA) CPT Staff • APA: Randy Phelps, Norman Anderson,  National Academy of Neuropsychology (NAN) Katherine Nordal (APA Testing & Psychotherapy Groups)  Division of Clinical Neuropsychology of APA (40) • NAN: PAIC Former and Present Committee  Center for Medicare & Medicaid Services (CMS) Medical Policy Staff- Medicare • National Psychologist: Paula Hartman-Stein  National Academies of Practice (NAP) • Other: James Georgoulakis, Neil Pliskin, Pat DeLeon (presented in chronological order of engagement of • (highly instrumental in recent CPT activities) support for the work outlined)

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Support Provided Personal Background (1988 – present)  North Carolina Psychological Association (e) • AMA = AMA pays travel and lodging for AMA CPT activities 2009-present  NAN’s Professional Affairs & Information Committee (a); Division (no salary, stipend and/or honorarium; stringent conflict of interest and 40 Practice Committee (a) confidentiality guidelines) • APA = Expenses paid for travel (airfare & lodging) associated with past  National Academy of Practice (e) CPT activities (no salary, stipend and/or honorarium historically nor at  APA’s Policy & Planning Board; Div. 40; Committee for present) Psychological Tests & Assessments (e); Ethics Committee • NAN = (from PAIO budget) Supported UNCW activities (no salary/honorarium obtained from stipend/paid to the university directly;  Consultant with the North Carolina Medicaid Office; North Carolina conflict of interest guidelines adhered to) from 2002-2009 Blue Cross/Blue Shield (a) • UNCW = University salary & time away from university duties (e.g.,  Health Care Finance Administration’s Working Group for Mental teaching) plus incidental support such as copying, mailing, telephone calls, Health Policy (a) and secretarial/limited work-study student assistance • Stipends = 100% goes to the UNCW Department of Psychology to fund  Center for Medicare/Medicaid Services’ Medicare Coverage training of students in neuropsychology Advisory Committee (fa)  American Medical Association’s Current Procedural Terminology Summary = AMA CPT includes travel/lodging support but no Committee Advisory Panel – HCPAC (IV/V) (a) salary/stipend.  American Medical Association’s Current Procedural Terminology – Any monies obtained, such as honoraria for presentations, are diverted Editorial Panel (e; rotating and permanent seat/second term) to the UNCW Department of Psychology for graduate psychology student training. No funds are used to supplement the salary or income of AEP.  Joint Committee for Standards for Educational and Psychological Tests (a) 10/28/2015 psychologycoding.com 5 10/28/2015 psychologycoding.com 6

psychologycoding.com 1 Standards & Guidelines for the Medicare: Local Review Practice of Psychology

• APA Ethics Code (2002) • Medical Review Policy • HIPAA and other federal regulations – National Policy Sets Overall Model • State or Province License Regulations – Local Coverage Determination (LCD) Sets • Contractual Agreements with Third Parties Local/Regional Policy- • More restrictive than national policy • Professional Standards (e.g., Standards for Educational and Psychological Tests, 2014) • Over-rides national policy • Changes frequently without warning or publicity • Applies to Medicare and private payers • Information best found on respective web pages

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CPT: Copyright CPT: Background

• American Medical Association • CPT is Copyrighted by the American Medical – Developed by Surgeons (& Physicians) in 1966 for Association Billing Purposes • CPT Manuals May be Ordered from the AMA at – 8,000+ Discrete Codes 1.800.621.8335 – CPT Meets a Minimum of 3 Times/Year • www.ama-assn.org/go/cpt • Center for Medicare & Medicaid Services – AMA Under License by CMS – CMS Now Provides Active Input into CPT – It is Regulatory and Would Take Congressional Action to Change

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CPT: Composition Base Codes • AMA House of Delegates – 122 Medical Specialties • The core or fundamental code • HCPAC • Typically billed once per event – 11 (?) Allied Health Societies (e.g., APA) • Provides the complete description of procedure • CPT Editorial Panel • Must be billed prior to subsequent and related – 17 Voting Members • 11 Appointed by AMA Board codes are billed • 1 each from BC/BS, AHA, HIAA, CMS • 2 Voted on by HCPAC – Psychologist (AEP) – Occupational Therapist

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psychologycoding.com 2 Add-on Codes Shifting Codes

• Further or expands what was started and • When a significant disruption of service occurs, described in the base codes a new service is then coded. • Base code must be billed prior to including add- • Assumption is that the professional would not on codes return relatively soon to the original service that was started. • May be billed multiple times • A continuous service is then broadly defined as the total number of units completed during the provision of that service.

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CPT: Applicable Codes Three Types of Codes • Psychiatric/Mental Health (1970s?) • Total Possible Codes = Approximately 8,000 • Possible Codes for Psychology = Approximately 70 • Neuropsychological (added in 1990s) • Sections = Five Primary Separate Sections • Health and Behavior (2000s) – Psychiatry (e.g., mental health) undergoing study & possible • Miscellaneous revision – Biofeedback – Preventative – Central Nervous System Assessment (testing) – Evaluation & Management (E & M) – Physical Medicine & Rehabilitation – Telehealth – Health & Behavior Assessment & Management – Team Conference – Applied Behavior Analysis – Evaluation and Management – Applied Behavior Analysis (Category 3)

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Psychiatric Diagnostic Psychiatric Codes Interviewing Paradigm • Neuropsychological • Health and Behavior Intensity Standard Complexity Interactive Complexity

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psychologycoding.com 3 Psychiatric Interviewing Psychiatric Interviewing - Includes examination of patient, exchange of 90791 information with (or in lieu of the patient other – History and Mental Status – Review and Order of Diagnostic Studies as needed informants such as nurses or family members and – Recommendations (including communication with preparation of report family or other sources) - Re-assessments are permitted (on different days)

90792 - Report more than once when separate interviews – Examination (CMS psychiatric specialty examination) are conducted with the patient and informant(s) – Prescription of Medications when appropriate - Do not report with psychotherapy (and crisis – Ordering of Laboratory Tests as needed codes)

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Psychotherapy Paradigm Psychotherapy Codes

TYPE of TIME of PSYCHOTHERAPY PSYCHOTHERAPY • Codes 90832-90838 describe time-based face-

Brief Regular Extended to-face services with the family and/or patient, with times of 30, 45, and 60 minutes.

Standard 30’ 45’ 60’ • The choice of code is based on the one that is closest to the actual time. In the case of the 30 minute codes, the actual time must have at least Interactive 30’ 45’ 60’ crossed the midpoint (16 minutes). • Psychotherapy is never less than 16 minutes. Crisis 30-74’ add for every undefined additional 30’

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Psychotherapy Psychotherapy: Basic Summary

Code Number Code Descriptor • 30 minutes = 16-37 mins. 90832 Psychotherapy, 30’ with patient and/or family member (other) • 45 minutes = 38-52 mins. 90833 Psychotherapy, 30’ with patient and/or • 60 minutes = 53 + mins. family member (other) with E & M 90834 Psychotherapy, 45’ with patient and/or • 90 minutes = family member (other) – Use 60 minute code plus 22 modifier, or 90836 Psychotherapy, 45’ with patient and/or family member (other) with E & M – Prolonged E & M service 90837 Psychotherapy, 60’ with patient and/or family member (other) 90838 Psychotherapy, 60’ with patient and/or family member (other) with E & M 99354, 99355, 99356, 993561 Psychotherapy, 90” with patient and/or family member 10/28/2015 psychologycoding.com 23 10/28/2015 psychologycoding.com 24

psychologycoding.com 4 Psychotherapy: Psychotherapy: Crisis Interactive Complexity • Codes 90839 and 90840 are time-based codes. • To report 90785 at least one of the following factors must be present: • Code 90839 is reported only once for the first 30-74 1. The need to manage maladaptive communication (related to, e.g., high anxiety, high reactivity, repeated questions, or disagreement) among minutes of psychotherapy for crisis on a given date, participants that complicates the delivery of care. even if the time spent by the physician or other 2. Caregiver emotions or behavior that interferes with the caregiver’s understanding and ability to assist in the implementation of the treatment plan health care professional is not continuous. 3. Evidence or disclosure of a sentinel event and mandated report to a third party (e.g., abuse or neglect with report to state agency) with initiation of discussion of the sentinel event and/or report with patient or other visit participants • Add-on code 90840 is used to report additional 4. Use of play equipment, other physical devices, interpreter or translator to block(s) of time of up to 30 minutes each beyond the communicate with the patient to overcome barriers to therapeutic or diagnostic interaction between the physician or other qualified health care professional and a patient who; first 74 minutes reported by 90839 (i.e., total of 75- 1. Is not fluent in the same language as the physician or other qualified health care professional, or 104 minutes, 105-134 minutes, etc.). 2. Has not developed, or has lost, either the expressive language communication skills to explain his/her symptoms and response to treatment or receptive skills to • Crisis coding (90839) must be at least 30 minutes in understand the physician or other qualified health care professional if he/she were to use typical language for communication duration. Otherwise code standard psychotherapy. (tip = time is determined by original base code) 10/28/2015 psychologycoding.com 25 10/28/2015 psychologycoding.com 26

Psychotherapy: RVUs Psychotherapy: Code Descriptor RVU Payment 90785 Interactive 0.11 14.33 Summary Complexity 90791 Psychiatric 2.80 133.98 Diagnostic Int. 90832 Psychotherapy; 1.25 64.84 Interview Psychotherapy Crisis Therapy 30 minutes T6 90832-90838 90834T4 Psychotherapy; 1.60 85.97 90791/90792 90839-90840 45 minutes 90838 Psychotherapy; 2.56 126.80 60 minutes Interactive Psychopharm 90839 Crisis Psy Rx; first Carrier Priced tbd Complexity 60 mins. Management 90840 Crisis Psy Rx: Carrier Priced tbd 90785 each 30 mins. 90863 Pharmacologic CMS based tbd Mngmt. 10/28/2015 psychologycoding.com 27 10/28/2015 psychologycoding.com 28

Neuropsychological Dx X Rx x Complexity (and Psychological) Testing

Psychotherapy Interview 90832-90838 • Psychiatric 90791/90792 (Group-90853) • Health and Behavior

Interactive Complexity 90785

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psychologycoding.com 5 Slide 27

T4 Changed from 90781 TeamSutton, 11/28/2012

Slide 28

T6 Changed from 90782 TeamSutton, 11/28/2012 Psychological Testing: Psychological Testing: By Professional (01.01.06) By Technician (01.01.06)

• 96102- Psychological Testing • 96101 –Psychological Testing – Psychodiagnostic assessment of emotionality, – Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, intellectual abilities, personality and personality and psychopathology, e.g., MMPI, psychopathology (e.g., MMPI, Rorschach, WAIS) Rorschach, WAIS) per hour of psychologist’s or with qualified health care professional physician’s time, both face-to-face time with the interpretation and report, administered by patient and time interpreting test results and technician, per hour of technician time, face-to- preparing the report. face

(estimated total per year Medicare claims = 175,000)

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Psychological Testing: Neurobehavioral Status Exam By Computer (01.01.06) (01.01.06; Revised 02.09.07; Implemented 01.01.08)

• 96103 - Psychological Testing • 96116 - Neurobehavioral status exam – Psychodiagnostic assessment of emotionality, – Clinical assessment of thinking, reasoning and intellectual abilities, personality and psychopathology, judgment ( e.g., acquired knowledge, attention, (e.g., MMPI) administered by a computer, with language, memory, planning and problem solving, qualified health professional interpretation and the and visual-spatial abilities) per hour of report psychologist’s or physician’s time, both face-to- face time with the patient and time interpreting test results and preparing the report

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Neuropsychological Testing- Neuropsychological Testing: By Professional (01.01.06) By Technician (01.01.06)

• 96118 - Neuropsychological testing • 96119 - Neuropsychological testing – (e.g., Halstead-Reitan Neuropsychological, – (e.g., Halstead-Reitan Neuropsychological, WMS, WMS, Wisconsin Card Sorting) per hour of the Wisconsin Card Sorting) with qualified health care psychologist’s or physician’s time, both face- professional interpretation and report, administered to-face time with the patient and time interpreting by a technician per hour of technician time, face-to- test results and preparing the report face (estimated total Medicare claims/year = 500,000)

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psychologycoding.com 6 Neuropsychological Testing- Screening Testing Code By Computer (01.01.06) (Effective 01.01.15)

• 96127 • 96120 - Neuropsychological testing • Brief emotional/behavioral assessment (e.g., – (e.g., WCST) administered by a computer depression inventory, attention-deficit, with qualified health care professional hyperactivity disorder (ADHD) scale, with interpretation and the report scoring and documentation, per standardized instrument

(CPT Insider’s Guide: 2015)

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Medicare National Payments Telehealth Services (2014-15) • Individual Psychotherapy Code Payment 96116 94.93 • Psychiatric Diagnostic Interviewing 96101 80.96 • All Health and Behavior Codes 96102 66.27 • Neurobehavioral Status Exam 96103 27.94 96118 99.24 • Presently discussing Testing Services 96119 81.32 96120 48.02

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Health and Behavior Health & Behavior: Assessment

• 96150 • Psychiatric – Health and behavior assessment (e.g., health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented • Neuropsychological questionnaires) – each unit = 15 minutes – face-to-face with the patient – initial assessment • 96151 – re-assessment – each unit = 15 minutes – Face-to-face with the patient

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psychologycoding.com 7 Health & Behavior: Intervention A Coding Model Psychiatric Neuropsych Health Psych • 96152 – Health and behavior intervention – each 15 minutes DSM ICD ICD – face-to-face – individual Interview Interview Interview • 96153 90791 96116 96150 – group (2 or more patients) ((usually 6-10 members)) • 96154 Testing Testing Testing – family (with the patient present) 96101 96118 96150 • 96155 – family (without the patient present; not being Therapy Rehab Rehab reimbursed) e.g., 90834 e.g., 96152 e.g., 96152 10/28/2015 psychologycoding.com 43 10/28/2015 psychologycoding.com 44

Medically Reasonable and The Present & Future of CPT Necessary Section 1862 (a)(1) 1963 • Applied Behavior Analysis (2014) 42, C.F.R., 411.15 (k) • PQRS (add on) (2014) • “Services which are reasonable and necessary for the • Expanded Evaluation & Management- diagnosis and treatment of illness or injury or to – Prolonged Service (2014) improve the functioning of a malformed body member” • Redoing H & B Codes (2015) • Re-evaluation should only occur when there is a • Redoing Testing Codes (2015) potential change in; – Diagnosis • Integrative Healthcare codes (2015) – Symptoms • Prevention or G Codes (2016?)

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Simple Explanation of Medical Necessity and Eventual Coverage

Existence of Evidence for World Health Organization’s Therapeutic Decision Making International Classification of Diseases and Related Health Problems -10th Edition (will it make a difference?) ICD-10

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psychologycoding.com 8 Acknowledgements Purpose of Presentation • Carol Goodheart, Ph.D. & Corwin Boake, Ph.D.

• Inmaculada Ibanez-Casas, Ph.D. & Zara Melikyan, • Describe ICD-10

Ph.D., Post-doctoral Fellows, UNCW • Discuss ICD-9, ICD-10 & DSM 5

• Debra Court (OPTUM) • Demonstrate ICD-10 and ICD-10-CM • American Psychological Association, Practice • Introduce ICD-11 Organization

• World Health Organization 49 50

Overview Overview •ICD as an unified diagnostic system •ICD as an unified diagnostic system

•ICD coding history and significance •ICD coding history and significance

•ICD in the US •ICD in the US

•ICD-10 description •ICD-10 description

•ICD-10. Chapter V: Mental and Behavioral Disorders •ICD-10. Chapter V: Mental and Behavioral Disorders

•Cultural issues in ICD-10 •Cultural issues in ICD-10

•Coding •Coding

•ICD and DSM (ICD-9, ICD-10 and DSM 5) •ICD and DSM (ICD-9, ICD-10 and DSM 5)

•Preview of ICD-11 •Preview of ICD-11

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ICD: Key Facts Benefits of ICD-10 •Global healthcare information standard (mortality & morbidity) > 100 countries Storage, retrieval, analysis and interpretation of data

•~ 70% of world’s health expenditure ($3.5 billion) is based ICD Sharing and comparisons: Endorsed by 43 member nations of World Health Assembly (1990).  Within populations  Between populations •Used by WHO member states since 1994  Compilation of international data •The standard of diagnostic nomenclature Health records

(Goodheart, 2013; World Health Organization) Tracking and trending of diseases Better and more descriptive clinical information

Better healthcare for patients

53 ICD-10 Interactive Self Learning Tool 54 (http://apps.who.int/classifications/apps/icd/icd10training/)

psychologycoding.com 9 ICD-10 Limitations: Diagnostic Coding “There are too many codes” DSM-IV-TR/5 used by behavioral health providers for diagnostic coding

~ 50% of all ICD-10CM (Clinical Modification) codes are related to the DSM-IV-TR/5 (& ICD-9) and ICD-10 codes closely coordinated: frequent but musculoskeletal system not always direct match ~ 25% of all ICD-10CM codes are related to fractures ICD-10 will be the only code permitted for billing on and after October 1, 2015 ~ 36% of all ICD-10CM codes are used to distinguish “right” vs. “left”

Meaning… ~ 70% of all charges are made for only 5% of codes

No ICD-10 = No reimbursement = No practice or profession Only a very small percentage of the codes will be used by most providers

National Council for Behavioral Health. 55 Health Data Consulting. 56 Preparing your organization for ICD-10 Implementation ICD-10 Clinical Documentation Requirements

Overview 120+ years of ICD History •ICD as an unified diagnostic system 1893 1909 1929 1948 1975 1990 2017 •ICD coding history and significance

•ICD in the US

•ICD-10 description

•ICD-10. Chapter V: Mental and Behavioral Disorders

•Cultural issues in ICD-10 ICD- 11 •Coding ICD-1 ICD- 4 ICD- 9 International List Categories Narrative descriptions •ICD and DSM (ICD-9, ICD-10 and DSM 5) of Causes based on of Mental & Behavioral of Death etiology disorders •Preview of ICD-11 ICD- 2 ICD- 6 ICD- 10 International List International of Causes Classification of of Sickness Diseases, Injuries and Death and Causes of Death 57 Mental, Psychoneurotic 58 and Personality Disorders

Overview ICD Implementation in the US •ICD as an unified diagnostic system 1979 - ICD-9-CM research and health statistics in the US •ICD coding history and significance

•ICD in the US 1983 - Reporting healthcare services for reimbursement in the US

•ICD-10 description 2013 - US begins using ICD-9-CM

•ICD-10. Chapter V: Mental and Behavioral Disorders ICD-9-CM - can not support current needs for health information •Cultural issues in ICD-10 ICD-10-CM implementation October 1, 2015 •Coding (Goodheart, 2013) •ICD and DSM (ICD-9, ICD-10 and DSM 5)

•Preview of ICD-11

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psychologycoding.com 10 ICD-10-CM: General Changes and Overview Overall Improvements •ICD as an unified diagnostic system •ICD coding history and significance

Greater pool of code numbers and diagnoses •ICD in the US

Combinations of codes used for symptom and •ICD-10 description

diagnosis, and etiology and manifestations •ICD-10. Chapter V: Mental and Behavioral Disorders

Guidelines to clarify priority of code •Cultural issues in ICD-10 assignments •Coding Subcategory titles are complete, no need to •ICD and DSM (ICD-9, ICD-10 and DSM 5) read previous codes to understand the meaning •Preview of ICD-11

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WHO Family of International ICD-10: Brief Overview Classifications ICD-10 International version ~12,500 diagnostic codes Used for mortality reporting in the US – 1999

ICD-10 – CM (Clinical Modification) - US version ~69,000 diagnostic codes 22 Chapters Chapter 5 – Mental/Behavioral (F01-F99)

ICD-10 Interactive Self Learning Tool 63 64 (http://apps.who.int/classifications/apps/icd/icd10training/) ICD-10 Interactive Self Learning Tool (http://apps.who.int/classifications/apps/icd/icd10training/)

ICD-10 Interactive Self Learning Tool 65 ICD-10 Interactive Self Learning Tool 66 (http://apps.who.int/classifications/apps/icd/icd10training/) (http://apps.who.int/classifications/apps/icd/icd10training/)

psychologycoding.com 11 ICD-10 Interactive Self Learning Tool 67 ICD-10 Interactive Self Learning Tool 68 (http://apps.who.int/classifications/apps/icd/icd10training/) (http://apps.who.int/classifications/apps/icd/icd10training/)

ICD-10 Online Browser: Core Codes ICD 10 –CM Online PDF

ICD-10 Online Browser (http://apps.who.int/classifications/icd10/browse/2015/en)

CAUTION: A “valid” (billable) code in F chapter includes 4-6 characters including the letter http://www.cdc.gov/nchs/icd/icd10cm.htm 69 70

ICD-10 at a Glance: 22 Chapters ICD-10 Organization Chapters Chapter # Chapter Title Alphab. code I Certain infectious and parasitic diseases A,B II Neoplasms C,D Block 1 Block 2 Block … III Diseases of the blood and blood-forming organs and D certain disorders involving the immune mechanism IV Endocrine, nutritional and metabolic diseases E V Mental and behavioural disorders F VI Diseases of the nervous system G Category 1 Category 2 CORE CODES VII Diseases of the eye and adnexa H VIII Diseases of the ear and mastoid process H IX Diseases of the circulatory system I Specific Specific X Diseases of the respiratory system J fourth fourth characters characther XI Diseases of the digestive system K

Supplementa ry Characters 71 72 ICD-10 Interactive Self Learning Tool (http://apps.who.int/classifications/apps/icd/icd10training/)

psychologycoding.com 12 ICD-10 at a Glance: 22 Chapters (Cont.) Overview Chapter # Chapter Title Alphab. code •ICD as an unified diagnostic system XII Diseases of the skin and subcutaneous tissue L XIII Diseases of the musculoskeletal system and connective M •ICD coding history and significance tissue XIV Diseases of the genitourinary system N •ICD in the US XV Pregnancy, childbirth and the puerperium O •ICD-10 description XVI Certain contidions originating in the perinatal period P XVII Congenital malformations, deformations and Q •ICD-10. Chapter V: Mental and Behavioral Disorders chromosomal abnormalities XVIII Symptoms, signs and abnormal clinical and laboratory R •Cultural issues in ICD-10 findings, not elsewhere classified XIX Injury, poisoning and certain other consequences of external S,T •Coding causes XX External causes of morbidity and mortality V,X,Y •ICD and DSM (ICD-9, ICD-10 and DSM 5) XXI Factors influencing health sttus and contact with health Z services •Preview of ICD-11 XXII Codes for special purposes U

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Chapter V: Introduction to Chapter V Mental and Behavioral Disorders “Mental and neurological disorders put greater disease burden than any Provides codes for mental and behavioral disorders other category, except communicable diseases.” Chapter uniqueness: descriptions of the disorders coded to each category that define the contents of the (WHO, 2008) categories.

Codes range: F00–F99.

75 ICD-10 Interactive Self Learning Tool 76 (http://apps.who.int/classifications/apps/icd/icd10training/)

Parts of Chapter V ICD-10: Disorder Description

Clinical Descriptions and Diagnostic Guidelines for general Main clinical features + important less specific features clinical, educational, and service use Number of possible diagnoses increases

Diagnostic Criteria for Research Overall diagnostic picture should not be clouded

“Provisional”/“Tentative” diagnosis (i.e., criteria partially met) Chapter V (F) - for compatibility with other classifications Symptom duration (general guideline)

Mental disorders arranged by major common themes

Descriptions and guidelines - set of symptoms and comments

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psychologycoding.com 13 ICD-10: Terminology: Basics ICD-10: Terminology: Basics

“Disorder" vs. “disease”/“illness”

Paradoxically, ICD is called International Classification of • Disease/illness – particular abnormal condition of DISEASES structure/function that affects part or all organism

“Psychogenic” not used - different meanings in different Disorder - set of symptoms or behaviors associated with languages and psychiatric traditions distress and interference with personal functions

If a external problem exists but does not affect the person or FOCUS IS ON DISORDERS others, it is not consifered a disorder and is not included

DISORDERS ARE FOCUSED ON SYMPTOMS

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ICD-10: Terminology (Cont.) ICD-10: Multiple Diagnoses Record as many diagnoses as necessary to cover the clinical “Impairment”, “disability”, and “handicap” used in accordance picture with International Classification of Impairments, Disabilities, and Handicaps (Geneva, WHO, 1980): One main or primary diagnosis and others as Impairment - “loss or abnormality … of structure or function”. subsidiary/additional/secondary…. Disability - “restriction or lack… of ability to perform an activity in the manner or within the range considered normal Most relevant diagnosis goes first (often the cause of consultation/contact of health services or “life-time” diagnosis) for human being”. Handicap - “disadvantage for an individual… that prevents If in doubt, list diagnoses in the order in which they appear in ICD or limits the performance of a role that is normal … for that individual” Recording diagnoses from other than chapter V is strongly recommended

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Overview •ICD as an unified diagnostic system

Defining •ICD coding history and significance Primary & Parent •ICD in the US •ICD-10 description Codes •ICD-10. Chapter V: Mental and Behavioral Disorders Primary = Core •Cultural issues in ICD-10 Parent = Etiology of pursued code •Coding Suggested Order = 1. Primary code 2. Parent code •ICD and DSM (ICD-9, ICD-10 and DSM 5) •Preview of ICD-11

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psychologycoding.com 14 Cultural Issues in ICD-10 Cultural Issues in ICD-10 Psychiatric diagnosis is based on cultural, social, biological Some indirect cultural relevance: and psychological factors Multi-axial Presentation of ICD-10 Increased interest in cultural framework of prospective Primary Health Version diagnostic systems Chapter XXI Factors Influencing Health Status and Contact In contrast, the presence of culture in ICD-10 is limited (vs. the with Health Services DSM 5) List of culture-specific disorders in Diagnostic Criteria for Research but not in the CM version

Mezzich et al., 2001 85 86

Culture-Specific Disorders in ICD-10 Overview •ICD as an unified diagnostic system Disorder Culture 1. Amok Malaysian •ICD coding history and significance 2. Dhat Indian •ICD in the US 3. Koro Indonesia, Thailand 4. Latah Southeast Asia •ICD-10 description 5. Ataque de Nervios Latin American Caribbean •ICD-10. Chapter V: Mental and Behavioral Disorders 6. Pa-leng (Frigophobia) China, Southeast Asia 7. Piblokto Inughuit societies living in Arctic Circles •Cultural issues in ICD-10 8. Susto, Espanto Latin American •Coding 9. Taijin Kyofusho Japanese •ICD and DSM (ICD-9, ICD-10 and DSM 5) 10. Ufufuyane, Saka Kenya, Southern Africa 11. Uqamairineq Inuit •Preview of ICD-11 12. Windigo Algonquian peoples in Atlantic coast and Great Lakes region in US and Canada

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ICD-10 Coding Coding steps: Additional Alpha Numeric Characters (Except U) 1. Determine the conditions that need to be coded

2. Use the Alphabetical Index (Vol 3) to locate the condition and allocate the code

F 1 3 2 2 1 3. Use the Tabular List (Vol 1) to check correct code assignment (e.g. inclusion note, exclusion note)

Added code Category Etiology, Anatomic S extensions for 4. Use the Instruction Manual (Vol 2) for any rules obstetrics, injuries and (Core Code) ite, Severity external causes of regarding the selection of a particular code for reporting injury mortality or morbidity data

CAUTION: A “valid” (billable) code in F chapter includes 4-6 characters including the letter

Blue Cross Blue Shield of Michigan (2014) 89 ICD-10 Interactive Self Learning Tool 90 ICD-10 Update. Mental and Behavioral Health ICD-10-CM Codes (http://apps.who.int/classifications/apps/icd/icd10training/)

psychologycoding.com 15 ICD-10 Golden Coding Rules ICD-10 Golden Coding Rules

Golden Coding Rule Number 1 Golden Coding Rule Number 2

Volumes 1 and 3 must be used together to correctly fin The special disease categories take priority over the d body system categories. codes for each case (e.g. cause of death or diagnosis)

ICD-10 Interactive Self Learning Tool 91 ICD-10 Interactive Self Learning Tool 92 (http://apps.who.int/classifications/apps/icd/icd10training/) (http://apps.who.int/classifications/apps/icd/icd10training/)

ICD-10 Golden Coding Rules ICD-10 Golden Coding Rules

Golden Coding Rule Number 3 Golden Coding Rule Number 4 The dagger code (†) is used as the underlying cause Be cautious of the spelling of the diseases you are coding since of death. Never use the asterisk code (*) alone if the the Tabular List uses British spelling and the Alphabetical index diagnosis being coded uses the dagger and asterisk uses American spelling. There are cross-references in the Index convention. to guide you to the American spelling.

Example: G22* = Parkinsonism in diseases classified elsewhere G22*, A52.1† = Syphilitic Parkinsonism

ICD-10 Interactive Self Learning Tool 93 ICD-10 Interactive Self Learning Tool 94 (http://apps.who.int/classifications/apps/icd/icd10training/) (http://apps.who.int/classifications/apps/icd/icd10training/)

Chapter V: Mental and Behavioral Revised Mental Health codes Disorders New concepts supported by ICD-10 ICD-10 “ ” “ ” “ ” F00-F09 Mental disorders due to known physiological conditions Drug use vs. dependence vs. abuse F01-F99 Mental, Behavioral and F10-F19 Mental and behavioral disorders due to psychoactive substance use Bipolar II Neurodevelopmental Disorders F20-F29 Schizophrenia, schizotypal, delusional, and other non-mood psychotic Bipolar disorders: distinction current episode / most disorders recent episode F30-F39 Mood (affective) disorders F40-F48 Anxiety, dissociative, stress-related, somatoform and other non- Recurrent depressive disorder psychotic mental disorders F50-F59 Behavioral syndromes associated with physiological disturbances and Mood disorder related to physiologic condition physical factors F60-F69 Disorders of adult personality and behavior

Adjustment insomnia F70-F79 Intellectual disabilities Adjustment reaction with withdrawal F80-F89 Pervasive and specific developmental disorders

F90-F98 Behavioral and emotional disorders with onset usually occurring in Asperger's syndrome childhood and adolescence Rett's syndrome F99-F99 Unspecified mental disorders

95 ICD-10 Interactive Self Learning Tool 96 Health Data Consulting. (http://apps.who.int/classifications/apps/icd/icd10training/) ICD-10 Clinical Documentation Requirements

psychologycoding.com 16 F00 Dementia in Alzheimer disease 4th Characters for use with categories F00-F09: F01 Vascular dementia F02 Dementia in other diseases classified elsewhere F03 Unspecified dementia F04 Organic amnesic syndrome, not induced by alcohol and other .0 Delirium, not superimposed on dementia psychoactive substances .1 Delirium, superimposed on dementia F05 Delirium, not induced by alcohol and other psychoactive substances .8 Other delirium F06 Other mental disorders due to brain damage and dysfunction and to .9 Delirium, unspecified physical disease F07 Personality and behavioral disorders due to brain disease, damage and dysfunction F09 Unspecified organic or symptomatic mental disorder ICD-10 Online Browser 97 ICD-10 Online Browser 98 (http://apps.who.int/classifications/icd10/browse/2015/en) (http://apps.who.int/classifications/icd10/browse/2015/en)

DSM-5 Classification DSM-5 Classification Major and Mild Neurocognitive Disorders (602) 1 stepMajor and Mild Neurocognitive Disorders (602) (cont.) 1 step Major Neurocognitive disorder due to traumatic brain injury (TBI) Probable major neurocognitive disorder due to Alzheimer’s disease ICD-9-CM code first 907.0 late effect of intracranial injury without skull fracture Code first 331.0 (G30.9) Alzheimer’s disease ICD-10-CM code first S06.2X96 diffuse TBI with loss of consciousness unspecified duration, Probable major neurocognitive disorder due to frontotemporal lobar degeneration sequela Code first 331.19 (G31.09) frontotemporal disease Major Neurocognitive disorder due to HIV infection Probable major neurocognitive disorder with Lewy bodies Code first 042(B20) HIV infection Code first 331.82 (G31.83) Lewy body disease Major Neurocognitive disorder due to Prion disease Probable major vascular neurocognitive disorder Code first 046.79 (A81.9) No additional medical code for vascular disease Major Neurocognitive disorder due to Huntington’s disease Major neurocognitive disorder probably due to Parkinson’s disease Code first 333.4 (G10) Huntington’s disease Code first 332.0 (G20) Parkinson’s disease Major Neurocognitive disorder due to another medical condition 2 step Code first the other medical condition Major Neurocognitive disorder due to Multiple etiologies ICD-9-CM ICD-10-CM Disorder, condition or problem 2 stepCode first all the etiologies of medical conditions (except for vascular disease) 294.11 F02.81 With behavioural disturbance ICD-9-CM ICD-10-CM Disorder, condition or problem

294.10 F02.80 Without behavioral disturbance 294.11 F02.81 With behavioural disturbance 294.10 F02.80 Without behavioral disturbance 331.9 G31.9 Possbile major neurocognitive disorder due to Alzheimer’s disease 331.83 G31.84 Mild neurocognitive disorder due to Alzheimer’s 99 100 331.83 G31.84 Mild neurocognitive disorder due to Alzheimer’s disease disease

DSM-5 Classification

F10 due to use of alcohol ProbableMajor major and vascular Mild neurocognitiveNeurocognitive disorder Disorders (602) (cont.) F11 due to use of opioids No additional medical code for vascular disease F12 due to use of cannabinoids F13 due to use of sedatives or hypnotics ICD-9-CM ICD-10-CM Disorder, condition or problem F14 due to use of cocaine 290.40 F01.51 With behavioural disturbance F15 due to use of other stimulants, including caffeine

290.40 F01.50 With behavioural disturbance F16 due to use of hallucinogens F17 due to use of tobacco 331.9 G31.9 Possible major vascular neurocognitive disorder F18 due to use of volatile solvents 331.83 G31.84 Mild vascular neurocognitive disorder F19 due to multiple drug use and use of other psychoactive substances 799.59 R41.9 Unspecified neurocognitive disorder CAUTION: ICD-10 codes presented (CORE CODES) = NON BILLABLE

101 ICD-10 Online Browser 102 (http://apps.who.int/classifications/icd10/browse/2015/en)

psychologycoding.com 17 DSM-5 Classification Substance-related and addictive disorders (481) (sample) 4th Characters for use with categories F10-F19: Alcohol use disorder .0 Acute intoxication Specify if in early remission/ in sustained remission .1 Harmful use Specify if in a controlled environment Specify the severity: .2 Dependence syndrome .3 Withdrawal state ICD-9-CM ICD-10-CM Disorder, condition or problem .4 Withdrawal state with delirium 305.00 F10.10 Mild

.5 Psychotic disorder 303.90 F10.20 Moderate .6 Amnesic syndrome 303.90 F10.20 Severe .7 Residual and late-onset psychotic disorder 303.00 Alcohol intoxication .8 Other mental and behavioural disorders .9 Unspecified mental and behavioural disorder F10.129 With use disorder, mild

CAUTION: Some 4 digits codes NOT BILLABLE (i.e. F19.1 alone) F10.229 With use disorder moderate to severe ICD-10 Online Browser 103 F10.929 Without use disorder 104 (http://apps.who.int/classifications/icd10/browse/2015/en)

DSM-5 Classification Schizophrenia spectrum and other psychotic disorders (87)

ICD-9-CM ICD-10-CM Disorder, condition or problem

F20 Schizophrenia 301.22 F21 Schizotypal personality disorder

F21 Schizotypal disorder 297.1 F22 Delusional disorder F22 Persistent delusional disorders 298.8 F23 Brief psychotic disorder F23 Acute and transient psychotic disorders 295.40 F20.81 Schizophreniform disorder 295.90 F20.9 Schizophrenia F24 Induced delusional disorder 295.70 F25.0 Schizoaffective disorder, bipolar type F25 Schizoaffective disorders 295.70 F25.1 Schizoaffective disorder, depressive type 293.81 F06.2 Psychotic disorder due to another medical condition, with F28 Other nonorganic psychotic disorders delusions F29 Unspecified nonorganic psychosis 293.82 F06.0 Psychotic disorder due to another medical condition, with halluciantions 293.89 F06.1 Catatonia associated with another mental disorder 293.89 F06.1 Catatonic disorder due to another medical condition 293.89 F06.1 Unspecified catatonia 298.8 F28 Other specified schizophrenia spectrum and other psychotic ICD-10 Online Browser 105 disorder 106 (http://apps.who.int/classifications/icd10/browse/2015/en) 298.9 F29 Unspecified schizophrenia spectrum and other psychotic disorder

F30 Manic episode F31 Bipolar affective disorder F32 Depressive episode ICD-9-CM ICD-10-CM Disorder, condition or problem 296._ _ F31._ _ Bipolar I disorder F33 Recurrent depressive disorder DSM-5296._ _ F32._ _ Classification Depressive disorders F34 Persistent mood [affective] disorders F38 Other mood [affective] disorders F39 Unspecified mood [affective] disorder

ICD-10 Online Browser 107 108 (http://apps.who.int/classifications/icd10/browse/2015/en)

psychologycoding.com 18 DSM-5 Classification

Anxiety disorders F40 Phobic anxiety disorders

F41 Other anxiety disorders ICD-9-CM ICD-10-CM Disorder, condition or problem F42 Obsessive‐compulsive disorder 309.21 F93.0 Separation anxiety disorder 312.23 F94.0 Selective mutism F43 Reaction to severe stress, and adjustment disorders 300.29 F40.2xx Specific phobia (e.g. animal, natural environment, etc.) F44 Dissociative [conversion] disorders 300.23 F40.10 Social anxiety disorder F45 Somatoform disorders 300.01 F41.0 Panic disorder 300.22 F40.00 Agoraphobia F48 Other neurotic disorders 300.02 F41.1 Generalized anxiety disorder 293.84 F06.4 Anxiety disorder due to another medical condition 300.09 F41.8 Other specified anxiety disorder CAUTION: PTSD code F43.1 NOT BILLABLE 300.00 F41.9 Unspecified anxiety disorder Valid code F43.10 (Found in DSM-5) CAUTION: All specific phobia codes need 6 digits to be billable

16 valid specific phobia codes, DSM-5 only 8 ICD-10 Online Browser 109 110 (http://apps.who.int/classifications/icd10/browse/2015/en)

Obsessive-compulsive and related disorders DSM-5Trauma- and Classification stressor-related disorders

ICD-9-CM ICD-10-CM Disorder, condition or problem ICD-9-CM ICD-10-CM Disorder, condition or problem 300.3 F42 Obsessive-compulsive disorder 313.89 F94.1 Reactive attachment disorder 300.7 F45.22 Body dysmorphic disorder 313.89 F94.2 Disinhibited social engagement disorder 300.3DSM-5 F42 Classification Hoarding disorder 309.81 F43.10 Posttraumatic stress disorder 312.39 F63.3 Trichotillomania 308.3 F43.0 Acute stress disorder 698.4 L98.1 Excoriation Adjustment disorders with: 294.8 F06.8 Obsessive-compulsive and related disorder due to another 309.0 F43.21 Depressed mood medical condition 309.24 F43.22 With anxiety 300.3 F42 Other specified obsessive-compulsive and related disorder 309.28 F43.23 With mixed anxiety and depressed mood 309.3 F43.24 With disturbance of conduct 309.4 F43.25 With mixed disturbance of emotions and conduct 309.9 F43.20 Unspecified 309.89 F43.8 Other specified trauma- and stressor-related disorder 111 309.89 F43.9 Unspecified trauma- and stressor-related 112 disorder

DSM-5 Classification

Feeding and eating disorders F50 Eating disorders F51 Nonorganic sleep disorders F52 Sexual dysfunction, not caused by organic disorder or disease F53 Mental and behavioral disorders associated with the puerperium, not ICD-9-CM ICD-10-CM Disorder, condition or problem 307.52 F98.3 Pica in children elsewhere classified 307.52 F50.8 Pica in adults F54 Psychological and behavioral factors associated with disorders or diseases 307.53 F98.21 Rumination disorder classified elsewhere 307.59 F50.8 Avoidant/restrictive food intake disorder F55 Abuse of non‐dependence‐producing substances 307.1 F50.01 Anorexia nervosa, restricting type F59 Unspecified behavioral syndromes associated with physiological 307.1 F50.02 Anorexia nervosa, binge eating/purging type disturbances and physical factors 307.51 F50.2 Bulimia nervosa 307.51 F50.8 Binge-eating disorder 307.59 F50.8 Other specified feeding or eating disorder CAUTION: DSM-5 does not include F53. 307.50 F50.9 Unspecified feeding or eating disorder In mood disorders, document if peripartum onset

ICD-10 Online Browser 113 114 (http://apps.who.int/classifications/icd10/browse/2015/en)

psychologycoding.com 19 DSM-5 Classification Personality disorders

ICD-9-CM ICD-10-CM Disorder, condition or problem F60 Specific personality disorders Cluster A personality disorders 301.0 F60.0 Paranoid personality disorder F61 Mixed and other personality disorders 301.20 F60.1 Schizoid personality disorder F62 Enduring personality changes, not attributable to brain damage and disease 301.22 F21 Schizotypal personality disorder Cluster B personality disorders F63 Habit and impulse disorders 301.7 F60.2 Antisocial personality disorder F64 Gender identity disorders 301.83 F60.3 Borderline personality disorder 301.50 F60.4 Histrionic personality disorder F65 Disorders of sexual preference 301.81 F60.81 Narcissistic personality disorder F66 Psychological and behavioural disorders associated with sexual Cluster C personality disorders development and orientation 301.82 F60.6 Avoidant personality disorder F68 Other disorders of adult personality and behaviour 301.6 F60.7 Dependent personality disorder F69 Unspecified disorder of adult personality and behaviour 301.4 F60.5 Obsessive-compulsive personality disorder Other personality disorders 310.1 F07.0 Personality change due to another medical condition 301.89 F60.89 Other specified personality disorder ICD-10 Online Browser 115 301.9 F60.9 Unspecified personality disorder 116 (http://apps.who.int/classifications/icd10/browse/2015/en)

4th Characters for use with categories F70-F79:

F70 Mild mental retardation F71 Moderate mental retardation .0 No, or minimal, impairment of behaviour F72 Severe mental retardation .1 Significant impairment of behaviour requiring attention or treatment F73 Profound mental retardation .2 Other impairments of behaviour F78 Other mental retardation .3 Without mention of impairment of behaviour F79 Unspecified mental retardation

ICD-10 Online Browser 117 ICD-10 Online Browser 118 (http://apps.who.int/classifications/icd10/browse/2015/en) (http://apps.who.int/classifications/icd10/browse/2015/en)

F80 Specific developmental disorders of speech and language F90 Hyperkinetic disorders F81 Specific developmental disorders of scholastic skills F91 Conduct disorders F82 Specific developmental disorder of motor function F92 Mixed disorders of conduct and emotions F83 Mixed specific developmental disorders F93 Emotional disorders with onset specific to childhood F84 Pervasive developmental disorders F94 Disorders of social functioning with onset specific to childhood and adolescence F88 Other disorders of psychological development F95 Tic disorders F89 Unspecified disorder of psychological development F98 Other behavioural and emotional disorders with onset usually occurring in childhood and adolescence CAUTION: DSM-5 does not include Asperger’s as independent diagnosis Under Autism Spectrum Disorders

ICD-10 Online Browser 119 ICD-10 Online Browser 120 (http://apps.who.int/classifications/icd10/browse/2015/en) (http://apps.who.int/classifications/icd10/browse/2015/en)

psychologycoding.com 20 DSM-5 Classification Neurodevelopmental disorders

ICD-9-CM ICD-10-CM Disorder, condition or problem Intellectual disabilities 319 F70 Intellectual disability, mild F99 Mental disorder, not otherwise specified 319 F71 Intellectual disability, moderate Incl.:Mental illness NOS 319 F72 Intellectual disability, severe Excl.:organic mental disorder NOS (F06.9) 319 F73 Intellectual disability, profound 315.8 F88 Global developmental delay 319 F79 Unspecified intellectual disability Communication disorders Autism spectrum disorder Attention-deficit/hyperactivity disorder Specific learning disorder Motor disorders Other neurodevelopmental disorders

121 ICD-10 Online Browser 122 (http://apps.who.int/classifications/icd10/browse/2015/en)

Frequent Mental Health Diagnoses:: General

Anxiety disorders Disorder ICD-10 category/code Autism spectrum disorders Depressive episode F32 Severe depressiveMost episode Frequent without psychotic Diagnoses: symptoms F32.2 Mood related disorders Dementia in AlzheimerMedicare-Medicaid disease F00* Schizophrenia Phobic anxiety disorders/other anxiety disorders F40/F41 Schizophrenia F20 Number and type of new concepts not foreign to Bipolar affective disorder F31 clinicians ADHD F90.9 Specific personality disorders F60 Reaction to severe stress and adjustment disorders/PTSD F43/F43.1 CAUTION: Core codes non billable. 123 At least 4 digits 124 Health Data Consulting. Centers for Medicare and Medicaid Services https://www.cms.gov ICD-10 Clinical Documentation Requirements * next to a code means that etiology code precedes that code

Overview •ICD as an unified diagnostic system

•ICD coding history and significance

Top 10Disorders Most Frequently ICD-10-CM codes •ICD in the US Dysthymic Reporteddisorder Diagnosis Codes: F34.1 •ICD-10 description Major depressive disorder, recurrent, moderate F33.1 Major depressive disorder, recurrentBC/BS severe without psychotic F33.2 •ICD-10. Chapter V: Mental and Behavioral Disorders features •Cultural issues in ICD-10 Major depressive disorder, recurrent, in remission, unspecified F33.40 Major depressive disorder, recurrent, unspecified F33.9 •Coding Generalized anxiety disorder F41.1 •ICD and DSM (ICD-9, ICD-10 and DSM 5) Anxiety disorder, unspecified F41.9 ADHD predominantly inattentive type F90.0 •Preview of ICD-11 Adjustment disorder with depressed mood F43.21 Major depressive disorder single episode, unspecified F32.9

125 126 Blue Cross Blue Shield http://www.bcbsm.com/content/dam/public/Providers/Documents/help/faqs/icd10-update-mentalhealth.pdf

psychologycoding.com 21 ICD and DSM Interfacing of DSM & ICD

ICD DSM Recall that the DSM is essentially the “borrowed” codes from ICD; DSM = descriptors of code # Developed by global UN agency Developed by a single national association Use parallel diagnostic system to the ICD in U.S. possible Free open resource for public Provides large portion of ApA due to harmonization efforts health benefit revenue For countries/service providers For (U.S.) behavioral health providers Few differences between ICD-9-CM and DSM-IV due to efforts to make them consistent Global, multidisciplinary, U.S. Anglophone perspective multilingual Approved by World Health Approved by ApA board of DSM-5 attempts to closely parallel ICD-10-CM Assembly trustees Covers all health conditions Covers only mental disorders DSM has to bridge ICD-9-CM, ICD-10-CM, ICD-11 (adapted from Goodheart, 2013)

(Goodheart, 2013; Reed, 2013)127 128

Sample Cross-Walk: ICD-10, ICD-9, DSM Coding Structure DSM-5 - ICD-9 - ICD-10 Sample 1: Depression

DSM-5/ICD-9-CM DSM-5/ICD-10-CM F33.2 DSM-5 Title ICD-9-CM Title ICD-10-CM Title Code1 Code2 F=Mental and Behavioral Disorders

Generalized anxiety 300.02 Generalized anxiety F41.1 Generalized anxiety disorder disorder disorder F30-39=Mood (affective) disorders Panic disorder without 300.01 Panic disorder without F41.0 Panic disorder agoraphobia agoraphobia F33=Recurrent Depressive Disorder Panic disorder with 300.21 + 300.22 Agoraphobia with panic F40.01 Agoraphobia with panic agoraphobia disorder disorder F33.2=Recurrent Depressive Disorder, current episode severe, without Persistent depressive 300.4 Dysthymic disorder F34.1 Dysthymic disorder disorder (dysthymia) psychotic symptoms

Schizophrenia, catatonic 295.90 + A293.89 Catatonic type F20.9 + F06.1 Catatonic schizophrenia type schizophrenia unspecified ICD-9-CM: 296.3 Major depressive disorder, recurrent episode

Bipolar I disorder, current 296.00 Bipolar I disorder single F31.1x Manic episode without or most recent episode manic episode unspecified psychotic symptoms, DSM-5 codes: 296.33 Major depressive disorder, recurrent, severe manic unspecified without psychotic features Specific Learning disorder 315.00 Developmental reading F81.0 Specific reading disorder with impairment in reading disorder unspecified Dementia of Alzheimer’s 290.10 Presenile dementia G30.9 + F02.80 Unspecified dementia type with early onset, uncomplicated without behavioral uncomplicated disturbance 1 in use through September 30, 2015 (Goodheart, 2 129 130 in use starting October 1, 2015 2013)

ICD-10, ICD-9, DSM Coding Structure Sample 2: Anxiety F40.01 F=Mental and Behavioral Disorders F40-F48=Anxiety, dissociative, stress-related, somatoform F40=Phobic Anxiety Disorders DSM Vs. ICD F40.0=Agoraphobia ICD is a Diagnostic System F40.01=Agoraphobia with panic disorder DSM is a Descriptive System ICD-9-CM/DSM-IV code: 300.21 Agoraphobia with panic disorder DSM-5: no category combines agoraphobia and panic CAUTION: no single code in DSM-5 combines Agoraphobia and Panic. Document both when present

131 132 (Goodheart, 2013)

psychologycoding.com 22 Overview ICD-11 Changes Overview •ICD as an unified diagnostic system Priorities: clinical utility & global applicability •ICD coding history and significance 2017 World Health Assembly (WHA) adoption •ICD in the US

•ICD-10 description Public revision of ICD-11 contents in May 2016

•ICD-10. ICD-10. Chapter V: Mental and Behavioral Disorders Regular (maybe yearly) updates

•Cultural issues in ICD-10 Greater number of diagnostic categories, less hierarchical structure, more clinically intuitive •Coding

•ICD and DSM (ICD-9, ICD-10 and DSM 5) New chapters on sleep disorders and sexual health •Preview of ICD-11 “Mental retardation” -> Intellectual developmental disorders

Personality disorders: severity, codification of prominent features instead of diagnostic entities. 133 134 (Adapted from

ICD-11: Involvement of Psychology ICD-11 Beta Draft Psychologists are more involved in ICD-11 than in other ICD revisions; Geoffrey Reed, Ph.D. (chair) & Pierre Ritchie, Ph.D. (board), Ann Watts, Ph.D (board)

Mental and Behavioral Disorders (MBD) chapter revised with significant contribution from APA and International Union of http://apps.who.int/classifications/icd11/browse/f/en Psychological Science

APA will recommend the use of ICD-11 instead of DSM-5 (Suzanne Bennet-Johnson said)

(Goodheart, 135 136 2013)

IMPORTANT: Practical Steps: #1 RARE GLIMPSE INTO ICD 11 UNCOVERED

Download the PDF version of ICD-10-CM codes free of charge from here: http://www.cdc.gov/nchs/icd/icd10cm.htm

Identify the ICD-9-CM/DSM 5 most commonly used diagnostic codes.

Find Cross-walked ICD-10 codes

Note that this link is NOT a browser and therefore the search will be manual

137 Adapted from American Psychological138 Association Practice Organization. Good

psychologycoding.com 23 Practical Steps: #2 Practical Steps: #3 < 09.30.15: Submit all claims for services Consider “saving” for the change provided before Sept. 30, 2015 using Submit few quick return claims at the beginning of October and follow the EOBs closely ICD-9-CM or DSM 5 codes Do not expect that the DXs that have been reimbursed for will be reimbursed again > 09.30.15: On and after October 1, 2015 Non-F codes may not be reimbursed though some LCD use only ICD-10-CM codes have listed other codes Consider contacting major carrier about the preceding 139 Share the information as to patterns of reimbursement 140

ICD X CPT Formulary Formulary - Third party payors (e.g., Medicare) will have a CPT (procedural code) X ICD (diagnostic code) that will be the basis of: ICD-9 Descript. ICD-10 Practical Steps: #4  Medical Necessity (examples for neuropsych- note some are F and others are  Reimbursement 290.10 UnspecifiedR codes) F03.90 Medicare - Each Medicare carrier will establish and Dementia publish on their website 780.83 Retrograde R41.2 Private Payors - Each carrier will establish and amnesia NOT publish in their website (trial and error) Other R41.2 amnesia

141 142

Billing Vs.Bill for Working the Dx being pursued Diagnosis The initial or working diagnosis then establishes the medical necessity for subsequent assessments and interventions It is new diagnosis that is used (e.g., Patient is referred for depression but evaluation discovered for dementia), bill for Diagnosing: depression for the first visit, but use dementia from that point forward Order & Number •First Diagnosis: Primary •Second Diagnosis: Next most important, and so on… •Total # of Diagnoses: All conditions present, including those diagnosed by you and those diagnosed by other qualified health providers

143 144

psychologycoding.com 24 Diagnosing: Assessment Vs. Treatment Overall Goal Assessment: Per previous slide, primary as discovered, then secondary and all other diagnoses Treatment: Per previous slide and as above but the diagnosis must match the treatment NOTE: Primary DX in each case will determine whether the CPT X DX claim is “medical” or “behavioral”. FORMULARY

145 146

Local Coverage Determinations (LCDs) Carrier Examples Contractor Index NOVITAS: https://www.cms.gov/medicare-coverage- https://www.cms.gov/medicare-coverage-database/details/lcd- database/indexes/lcd-contractor- details.aspx?LCDId=35101&ContrId=338&ver=8&ContrVer=1&Date=10%2f01%2 f2015&DocID=L35101&bc=iAAAAAgAAAAAAA%3d%3d& index.aspx?bc=AgIAAAAAAAAAAA%3d%3d& CIGNA: State Index https://cignaforhcp.cigna.com/public/content/pdf/coveragePolicies/medical/ https://www.cms.gov/medicare-coverage- mm_0258_coveragepositioncriteria_neuropsychological_testing.pdf database/indexes/lcd-state- AETNA: index.aspx?bc=AgIAAAAAAAAAAA%3d%3d& http://www.aetna.com/cpb/medical/data/100_199/0158.html Alphabetical Index (NOTE: Neuropsychological testing is covered for the following types of https://www.cms.gov/medicare-coverage- diagnosis- F; NP testing is covered for F, G as well as some I, Q, R and S codes.) database/indexes/lcd-alphabetical-

index.aspx?DocType=All&bc=AgAAAAAAAAAAAA%3d%3147 148 d&

To be Determined Core codes, more than three, or full seven digits? How deep do you for billing and for reports? Number of places for DX has gone from 6 to 12. Besides Chapter 5 (F), what other chapters can and should be Primary code and, if appropriate or necessary, the parent code used? following What about the use of non-F codes for neuropsychological and HCFACurrent version 1500 is v02/12 health psychology situations? Includes an ICD Indicator in Field 21 What about parent codes? Use “9” for filing a claim with ICD-9 Codes (before 9/30/15) Some traditional DXs may not be present or covered (G31.84 or MCI) Use “0” for filing a claim with ICD-10 Codes (on and after 10/1/15) BOTTOM LINE: FORMULARY OF CPT X ICD

Valid codes can be 3-7 digits: ICD-10-CM is the standard for billing F = 3-7 digits; 149 150 S = 7 digits

psychologycoding.com 25 Useful Resources Useful Resources (Cont.) WHO ICD-10 Description: CMS Road to 10 http://www.who.int/classifications/icd/en/ http://www.roadto10.org/ WHO “Bluebook”: http://www.roadto10.org/webcasts/ http://www.who.int/classifications/icd/en/bluebook.pdf AAPC ICD-10 Training: ICD-10 Browser: https://www.aapc.com/icd-10/training.aspx http://apps.who.int/classifications/icd10/browse/2015/en ICD-10-CM/PCS Basics for Clinical Documentation Improvement, American Health Information ICD-10 Interactive Self Learning Tool: Management Association Library, http://apps.who.int/classifications/apps/icd/icd10training/ http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_050416.pdf ICD-10 Online Support: ICD-10 and DSM-5 Frequently Asked Questions, Minnesota Department of Human Services: https://sites.google.com/site/icd10onlinetraining/ http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSe lectionMethod=LatestReleased&dDocName=dhs16_182682 Transition to the ICD-10-CM, APA Practice Central: http://www.apapracticecentral.org/update/2012/02-09/transition.aspx Understanding ICD-10-CM and DSM-5, American Psychiatric Association: https://www.appi.org/File%20Library/Products/APP_DSM5_Resources_Understanding_ICD.pdf ICD-10 Code Transition, Magellan Healthcare: http://www.magellanprovider.com/getting-paid/preparing-claims/icd10-code-transition.aspx Understanding ICD-10: National Council for Behavioral Health: http://www.kareo.com/documents/ICD10_eBook_Mental_Health.pdf http://www.thenationalcouncil.org/topics/coding-behavioral-health-services/ Understanding the ICD-10 The Clinician’s Toolbox: http://www.thenationalcouncil.org/wp-content/uploads/2013/01/ICD10_onepager.pdf www.theclinicianstoolbox.com. Centers for Medicare and Medicaid Services: DSM-5 to ICD-9 Crosswalk, Alliance Behavioral Healthcare: http://www.cms.gov/Medicare/coding/ICD10/index.html https://www.alliancebhc.org/wp-content/uploads/DSM5-ICD9-Crosswalk.pdf http://www.cms.gov/Medicare/Coding/ICD10/index.html?redirect=/ICD10/ http://www.cms.gov/Medicare/Coding/ICD10/ProviderResources.html 151 DSM-5 and ICD-10 Resources, Optum: 152 http://www.cms.gov/eHealth/downloads/Webinar_eHealth_August5_Roadto10.pdf https://www.providerexpress.com/content/ope-provexpr/us/en/admin-resources/dsm5_icd10.html

Useful Links Useful Resources (Cont.)

ICD 9/10 Crosswalk: http://ncmmis.ncdhhs.gov/icdxwalk.asp (Members only through my.apa.org login) http://icd10cmcode.com http://www.guilford.com/add/frances2/crosswalk-alph.pdf http://www.azaleahealth.com/wp-content/uploads/Psychiatry-ICD10-Crosswalk.pdf ICD 9/10 Conversion: http://www.icd10data.com

DSM-V: http://eahec.ecu.edu/brochures/e43633.pdf

Medical billing and coding ICD-10: https://www.encoderpro.com/epro/ http://www.pulseinc.com/wp-content/uploads/2013/10/MentalBehavioral_ICD10Conversion.pdf

153 154

Useful Apps Useful Apps

iOS & Android iOS iOS Only

MTBC ICD 9-1 0 ICD-10 On the Go Codes by Specialty ICD-10 HCPCS ICD-9 ICD-10 Free ICD-10 Codes Free ICD10 Consult Medical Codes Ideal for Physicians DxCodeMapper Detailed descriptions Android of codes

Quick ICD 10 Simple conversion, no details ICD-10 & ICD-9 ICD-10: Codes of 155 ICD-10 ICD-10 Navigator 156 Code Reference Diseases

psychologycoding.com 26 ICD 10 Primer: Carol Goodheart Pricing of Codes

• Carrier Based •CMS • AMA RUV (most widely accepted) A Primer for ICD-10-CM Users: Psychological and Behavioral Conditions Cover of A Primer for ICD-10-CM Users

List Price: $19.95

American Psychological Association

Member/Affiliate Price: $14.95

Pages: 171 157 10/28/2015 psychologycoding.com 158 Item #: 4317336

Developing a Fee Schedule Alternative Payment Models • Medicare • Quality Metrics – Conversion Factor • 2008 = $34.1350 • Outcome Metrics • 2015 = $35.9335 • Bundled Payment/Episode Care System • Standard Method of Developing Fee Schedule • Population Based Systems (e.g., Accountable – Obtain Medicare RVU values for selected CPT Care System) codes – Multiply by 150% • CPT is excellent for single episode of care – Revise fee schedule as RVUs change

10/28/2015 psychologycoding.com 159 10/28/2015 psychologycoding.com 160

Health Care Bill: How Health Care Will Be Revolutionized by 2018 Emerging Patterns

Bill: • Shift from Pre to Post "Authorizations" http://thomas.loc.gov/cgi-bin/bdquery/z?d111:H.R.4872 • Documentation is Support for Medical Necessity • Medical Necessity is the Basis for the Service Timetable: • Integrative http://www.commonwealthfund.org/Content/Publications/Ot her/2010/Timeline-for-Health-Care-Reform- • Health Care Delivery Implementation.aspx#2010 • Shift of Focus from Federal to State (also, www.healthcare.gov) • Accuracy, Transparency and Utility • Performance Based (but metrics being developed) • Fast Moving, Major Paradigm Shifting

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psychologycoding.com 27 A Summary of Approximately 25 Bottom Line Years

• Expanded from a Approximately 3-4 Codes to Over 1. Who gets paid? Several Dozen Codes and Continuously Expanding • Total Revision of all Diagnostic, Testing and »Bundled (e.g., ACA, hospitals, etc.) Psychotherapy Codes and addition Health & Behavior »Individual (i.e., Qualified Health • Addition of Prescription Privilege Code Provider) • Expanded from Psychiatric Only to All of Medicine • Expanded from No Uniformity and Lack of 2. How do they get paid? Understanding to High Levels of Professionalism and »RVBRS Recognition & Collaboration With Medicine/Health Care • Reimbursement Increases Has Outpaced Other Health »Performance based Care Disciplines by a Significant Factor

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Resources And “I feel fine” • General Web Sites – www.ama-assn.org/go/cpt (CPT) http://www.apamonitor- – www.apa.org (general APA website) – www.apapracticecentral.org (resources for practicing psychologists) digital.org/apamonitor/201212/?pg=70&pm=2&u1= – www.nanonline.org/paio (practice patterns & information) friend – www.apa.org/practice/cpt (APA’s CPT information) – www.cms.org (medicare/medicaid) – www.hhs.org (health & human services) – www.oig.hhs.gov (inspector general) – www.ahrq.gov (agency for healthcare research) – www.medpac.gov (medical payment advisory comm.) – www.whitehouse.gov/fsbr/health (statistics) – www.div40.org (clinical neuropsychology div of APA) – www.napnet.org (national association of psychometrists) – www.psychometristscertification.org (board of certified psychometrists) – www.access.gpo.gov (federal statutes and regulations) – www.healthcare.group.com (staff salaries) – www.commonweath.com (health care policy)

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Resources (continued) Resources (continued)

• Payment/Coverage •ICD – www.myhealthscore.com/consumer/phyoutcptsearch.htm – www.who.int/icd/vol1htm2003/fr-icd.htm (who) – www.cms.hhs.gov/statistics/feeforservice/defailt.asp (covered services) – www.cms.hhs.gov/mcd/viewtrackingsheet.asp?id=167 (non-covered) – www.cdc.gov/nchas/about/otheract/icd9/abticd9.htm (ccd) – www.apa.org/pi/aging/lmrp/toolkit/homepage.html (APA lCD) – www.cms.hhs.gov/providers/mr/lmrp/asp (medicare lmrp) •PQRS – www.quickfacts.census.gov/qfd (census x type of procedure data) – www.centerforhealthyaging.com – www.usqualitymeasures.org (payment for performance) • LMRP Reconsideration Process • Coding Web Sites – www.cms.gov/manuals/pm_trans/R28PIM.pdf •PQRS – www.catalog.ama- – www.centerforhealthyaging.com assn.org/Catalog/cpt/cpt_search.jsp (AMA CPT) • Compliance Web Sites – www.oig.hhs.gov (office of inspector general) – www.aapcnatl.org (academy of coders) – www.cms.hhs.gov/manuals (medicare) – www.uscode.house.gov/usc.htm (united states codes) – www.ntis.gov/product/correct-coding (coding edits) – www.apa.org (psychologists & HIPAA) – www.cms.hhs.gov/hipaa. (HIPAA) – www.hcca-info.org (health care compliance assoc.) – www.cms.gov/oas/cms.asp

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psychologycoding.com 28 Additional Sample Forms AMA Contact Information

• Office Forms • Website – CPT Routing – www.amabookstore.com –PQRS – Link to; • Clinical Forms • catalog.ama-assn.org/Catalog/cpt/issue_search.jsp – Psychiatric Interviewing • Telephone – Psychotherapy – 312.464.5116 – Neurobehavioral Status Exam – Neuropsychological Testing (prof & technical)

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APA Contact Information Puente Contact Information

• American Psychological Association • Websites - Katherine Nordal, Ph.D. – Coding = www.psychologycoding.com Practice Directorate, Director – University = www.uncw.edu/people/puente American Psychological Association – Practice = www.clinicalneuropsychology.us 750 First Street, N.W. – Vita/Academic = www.antonioepuente.com Washington, D.C. 20002 • Association for the Advancement of Psychology • E-mail – University = [email protected] – www.aapnet.org – Practice = [email protected] – P.O.Box 38129 – Colorado Springs, Colorado 38129 • Telephone – University = 910.962.3812 – Practice = 910.509.9371

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Antonio E. Puente, Ph.D. University of North Carolina Wilmington [email protected]

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