ICD-10-CM, DSM 5 and Diagnostic Discrepancies For Somatic, Sleep and Adjustment Disorders Daniel Bruns, PsyD Within the United States it has been traditional to use the DSM for 5/ICD-10-CM discrepancies were partially resolved by creating a system of psychiatric diagnoses. Elsewhere in the world, the ICD has been the “crosswalks”, where by a DSM 5 diagnosis is crosswalked to the ICD-10-CM dominant psychiatric diagnostic system. When the Federal government diagnosis that corresponds most closely to it. In some cases though, was contemplating implementing the ICD-10-CM for both medical and diagnostic information can be lost or distorted in translation. psychiatric diagnoses, the Federal Register noted that a complication was that the DSM 5 had yet to be published. It was recognized that this created The diagnostic discrepancies caused by crosswalks are sometimes regarded the possibility of diagnostic code conflicts as the ICD-10 paralleled the as insignificant as they are only used for “billing and coding”, and the DSM-IV, and the aspiration was that this could be prevented.1 The Federal psychiatric records contain the actual diagnosis being used in treatment. Register reported that the CDC’s wish was the DSM 5 would remain aligned However, it is important to remember that the ICD-10 diagnostic code is with the ICD-10, stating the following: the least private aspect of protected health information, as payers generally require this code for reimbursement. So while a patient’s medical We also note that the Diagnostic and Statistical Manual of Mental records may discuss a DSM 5 diagnosis, what the payer receives is an ICD- Disorders, Fifth Edition (DSM–V) is projected to be released in 10 diagnosis. Later on, if a patient is applying for a loan, life insurance, 2012 by the American Psychiatric Association (APA). CDC is security clearance etc., this ICD-10 diagnostic finding is the most likely working with APA to ensure that ICD–10–CM and DSM–V codes information to be available. Thus, if a patient’s medical records contain the match, and that the timing of this projected release would diagnosis DSM 5 F45.1 Somatic Symptom Disorder (based on unhelpful conform with the commenter’s request that the ICD–10 cognitions about a medical condition), HIPAA requires that this diagnosis compliance date occur after the release of DSM–V (p3334). be crosswalked to the closest ICD-10 diagnosis, which is F45.1 Undifferentiated somatoform disorder (vague and ill-defined symptoms Although this goal was mostly realized, the DSM 5 and the ICD-10-CM have without clear medical explanation). Regardless of the medical records, significant discrepancies. The single largest discrepancy is that the DSM 5 undifferentiated somatoform disorder becomes the “official” diagnosis as re-conceptualized the entire somatoform category of diagnoses, omitting far as payers are concerned, and is the diagnosis that is most easily the concept altogether and replacing it with a new diagnostic concept accessed by others or by “big data” systems. Consequently, it is important called somatic symptom disorders. However, the ICD-10-CM corresponds to be aware of the implications of ICD-10 crosswalks when assigning DSM 5 more closely with DSM-IV, as they were developed concurrently. DSM diagnoses. Additionally, it is also important to remember that under 1 Elsewhere in the Federal Register the possibility of complications arising from two logistical issues and add to the complexity of the ICD–10 code set implementation.” differing diagnostic code sets was discussed in a different context, that of ICD–9– In this case however, the concerning conflicts were between ICD-10-CM/DSM-IV CM versus ICD–10–CM. “We agree with commenters that maintenance of two code and DSM-5 diagnostic systems. sets for a significant span of time such that, on any specific date of service in that time frame one could submit, process and/or receive payment on a claim based on ICD–9–CM or the ICD–10–CM and ICD– 10–PCS code sets would raise considerable 1 Federal law ICD-10-CM psychiatric diagnoses are valid, even if they are not system. contained in DSM IV or DSM 5. While many non-DSM 5 ICD-10 diagnoses are closely parallel to DSM-IV, some ICD-10 diagnoses are not contained in In ICD-10-CM (American Version), the diagnosis of pain disorder is assigned either DSM system, but nevertheless are recognized diagnostic constructs to patients with chronic pain. Pain Disorder has two subtypes. The first, under HIPAA. F45.41 “Pain disorder associated with psychological factors” is a psychological or stress-related condition that is neither precipitated by nor With regard to chronic pain, guidelines have noted that the term “chronic associated with any objective pathophysiology (e.g. chronic tension pain syndrome” (G89.4) has been incorrectly used and defined in a variety headache). The second, F45.42 “Pain disorder with related psychological of ways that generally indicate a belief on the part of the health care factors” is a biopsychosocial diagnosis where pain is believed to be provider that the patient's pain is inappropriate or out of proportion to associated with both medical and psychological diagnoses (e.g. herniated existing problems or illness. Use of the term “chronic pain syndrome” lumbar disc and depression). Note that the ICD-10-CM diagnosis of Pain should be discontinued because the term ceases to have meaning due to Disorder is more closely associated with DSM-IV-TR concepts than it is with the many different physical and psychosocial issues associated with it. The DSM 5, and that the DSM 5 diagnosis of “Somatic Symptom Disorder, Pain IASP offers taxonomy of pain, which underscores the wide variety of Predominant” has no exact equivalent in ICD-10-CM. While the DSM-IV-TR pathological conditions associated with chronic pain. This classification diagnosis of Pain Disorder was diagnosed in part by “medically unexplained system may not address the psychological and psychosocial issues that symptoms,” this is now believed to be a misleading criterion. When F45.42 occur in the perception of pain, suffering, and disability and may require is diagnosed, the code for the associated medical diagnosis should also be referral to psychiatric or psychological clinicians. Practitioners should use provided. the nationally accepted terminology indicated in the most current ICD 2 Diagnosable Somatic & Sleep Disorders ICD-10-CM and Related DSM-IV and DSM 5 Disorders Listed in ICD-10-CM Diagnosable Code # DSM DSM DSM 5 Name Comments Conditions IV 5 F44 Dissociative and conversion Unbillable Dx category disorders F44.4 Conversion disorder with motor Conversion disorder (a.k.a. DSM-5 specify if: Weakness or paralysis; symptom or deficit X X functional neurological Abnormal movement; Swallowing symptoms disorder) symptoms; Speech symptoms F44.5 Conversion disorder with seizures or X convulsions F44.6 Conversion disorder with sensory Conversion disorder with X X symptom or deficit sensory symptoms F44.7 Conversion disorder with mixed Conversion disorder with X X symptom presentation mixed symptoms F44.8 Other dissociative and conversion Unbillable Dx category disorders F44.89 Other dissociative and conversion disorders F44.9 Dissociative and conversion disorder, unspecified F45 Somatoform disorders Unbillable Dx category F45.0 Somatization disorder X ICD-10 Dx applicable to Briquet's disorder definition of somatization F45.1 Undifferentiated somatoform Somatic symptom disorder DSM-5 changed diagnostic concept disorder X XXX Specify: predominant pain; if persistent; severity F45.2 Hypochondriacal disorders Unbillable Dx category F45.20 Hypochondriacal disorder, unspecified F45.21 Hypochondriasis Illness anxiety disorder DSM-5 changed diagnostic concept X XXX Specify whether: care seeking / care avoidant type F45.22 Body dysmorphic disorder X X Body dysmorphic disorder 3 F45.29 Other hypochondriacal disorders F45.4 Pain disorders related to Unbillable Dx category psychological factors F45.41 Pain disorder exclusively related to X psychological factors F45.42 Pain disorder with related X psychological factors F45.8 Other somatoform disorders X F45.9 Somatoform disorder, unspecified X F68 Other disorders of adult personality Unbillable Dx category and behavior F68.1 Factitious disorder Unbillable Dx category F68.10 Factitious disorder, unspecified Factitious disorder Includes both DSM 5 factitious disorder X X and factitious disorder imposed on another F68.11 Factitious disorder with predominantly psychological signs X and symptoms F68.12 Factitious disorder with predominantly physical signs and X symptoms F68.13 Factitious disorder with combined psychological and physical signs and X symptoms F54 Psychological or behavioral factors Psychological factors In ICD-10-CM F54 is a “manifestation associated with disorders or diseases X X affecting other medical code.” First code the associated physical classified elsewhere conditions disorder G47 Sleep disorders Unbillable Dx category G47.0 Insomnia Unbillable Dx category G47.00 Insomnia unspecified X X Insomnia disorder G47.01 Insomnia due to medical condition G47.09 Other insomnia X G47.1 Hypersomnia Unbillable Dx category G47.10 Hypersomnia, unspecified X X Hypersomnolence disorder G47.11 Idiopathic hypersomnia with long sleep time 4 G47.12 Idiopathic hypersomnia without long sleep time G47.13 Recurrent hypersomnia G47.14 hypersomnia due to medical condition G47.19 Other hypersomnia Other specified X hypersomnolence disorder G47.2 Circadian rhythm sleep disorders Unbillable Dx category