Clinicians should be aware of several changes to the codes attached to diagnoses in DSM-5.
The changes and updates, and any future ones, can be accessed at APA’s DSM-5 website (http://www.dsm5.org).
The recently released manual, like all previous versions of DSM, uses coding designations from the International Classification of Diseases, Clinical Modification (ICD-9-CM), as well as the forthcoming 10th edition (ICD-10-CM), to allow clinicians to code for specific mental disorders. The ICD-CM is the official system of assigning codes to diagnoses in the United States.
APA Director of Research Darrel Regier, M.D., M.P.H., explained that since the ICD system has been created independently of the DSM system, it was necessary for DSM-5 to use the closest approximation of ICD-CM codes to classify diagnoses for insurance claims and other research and public-health purposes.
“The benefit of the DSM process is that it has been able to provide a level of scientific review of mental disorders that is extensive and beyond that provided by the World Health Organization—which oversees development of the ICD—and the Centers for Disease Control and Prevention’s National Center for Health Statistics [NCHS]—which, with the Centers for Medicare and Medicaid Services [CMS], oversees revisions to all clinical modifications [CM] of the ICD for the United States,” he said. “For that reason, DSM is widely used by CMS contractors for quality assessment and by insurance companies and federal and state agencies to indicate eligibility for services.”
But Regier said that unlike the DSM-5 criteria and text that describes the criteria—both of which are relatively stable—the coding system is subject to annual revisions by NCHS and CMS in their review conferences held twice a year.
As of late September, the following changes and refinements to the coding system have been implemented and posted on the http://www.dsm5.org website:
Intellectual disability (intellectual developmental disorder): The new ICD-9-CM codes (and ICD-10-CM codes, which follow in parentheses) that should be used to indicate severity are 317 (F70) Mild, 318.0 (F71) Moderate, 318.1 (F72) Severe, and 318.2 (F73) Profound.
Language disorder: The new ICD-9-CM code (and ICD-10-CM code) that should be used is 315.32 (F80.2).
Bipolar I disorder, current or most recent episode hypomanic, in partial remission: The updated ICD-9-CM code (and ICD-10-CM code) that should be used is 296.45 (F31.71).
Bipolar I disorder, current or most recent episode hypomanic, in full remission: The updated ICD-9-CM code (and ICD-10-CM code) that should be used is 296.46 (F31.72).
Selective mutism: The new ICD-9-CM code (and ICD-10-CM code) that should be used is 313.23 (F94.0).
Trichotillomania (hair-pulling disorder): The new ICD-9-CM code (and ICD-10-CM code) that should be used is 312.39 (F63.3).
Insomnia disorder: The new ICD-9-CM code (and ICD-10-CM code) that should be used is 307.42 (F51.01).
Hypersomnolence disorder: The updated ICD-9-CM code (and ICD-10-CM code) that should be used is 307.44 (F51.11).
Conduct disorder, adolescent-onset type: The updated ICD-9-CM code (and ICD-10-CM code) that should be used is 312.82 (F91.2).
Kleptomania: The updated ICD-9-CM code (and ICD-10-CM code) that should be used is 312.32 (F63.2).
In addition, clinicians should be aware of newly implemented coding recommendations for neurocognitive disorders. As currently reflected in DSM-5, the diagnoses of major neurocognitive disorder possibly due to Alzheimer’s disease, frontotemporal lobe degeneration, Lewy bodies, and Parkinson’s disease do not use additional codes to indicate the presence of behavioral disturbances—a major reason for psychiatric and other mental health service interventions for neurocognitive disorder treatment.
Consequently, APA is revising codes for these four disorders to include codes that indicate the presence (294.11 [F02.81]) or absence (294.10 [F02.80]) of a behavioral disturbance—resulting in a recommendation to use the same code for both probable and possible etiologies of these major neurocognitive disorders.
“For these conditions, there is no question about meeting the criteria for a major neurocognitive disorder and the need for intervention if behavioral disturbances are present,” Regier explained. “The causal attribution level of evidence for the possible or probable designation is a useful guide for treatment selection, but is not as important as the presence or absence of behavioral disturbances for indicating the need for psychiatric and other behavioral health interventions.”
And last month APA presented seven diagnoses that are new to DSM-5, along with proposals for new codes that will be used, to the CDC/NCHS and CHS/CMS at their annual ICD review conference. The new codes, if approved, would probably not be added to ICD-10-CM until 2015. These are among the proposed changes:
Binge eating disorder (BED): This disorder is not listed in ICD-9-CM or ICD-10-CM. In ICD-9-CM, it is coded with the same code as bulimia nervosa (307.51). APA is recommending that BED be added to ICD-10-CM and temporarily be given the same code as “other” eating disorders (F50.8). APA also has asked the NCHS to consider giving BED its own code in the future, rather than having to continually share the same code as “other eating disorders.”
Disruptive mood dysregulation disorder: This disorder is not listed in ICD-9-CM or ICD-10-CM. In ICD-9-CM, it is coded with the same code as other specific episodic mood disorder (296.99). APA is recommending that this disorder be added to ICD-10-CM and temporarily be given the same code as other persistent mood (affective) disorder (F34.8) until a unique code can be approved in the ICD revision conference.
Social (pragmatic) communication disorder: This disorder is not listed in ICD-9-CM or ICD-10-CM. In ICD-9-CM, it is coded with the same code as other developmental speech or language disorder (315.39). APA is asking that this disorder be listed under other developmental disorders of speech and language (F80.89). Further, APA is asking that the ICD-10-CM note that use of this code excludes use of the code for autism spectrum disorder (ASD), as children with ASD have a presentation different from those with social (pragmatic) communication disorder.
Hoarding disorder: This disorder is not listed in ICD-9-CM or ICD-10-CM. In ICD-9-CM, it is coded with the same code as obsessive-compulsive disorders (OCD) (300.3). APA is recommending that hoarding disorder be added to ICD-10-CM and temporarily be given the same code as obsessive-compulsive disorder (OCD; F42). However, given that hoarding disorder and OCD are distinct conditions, APA prefers that the NCHS eventually assign unique codes in future revisions for both OCD and hoarding disorder.
Excoriation (skin picking) disorder: This disorder is not listed in ICD-9-CM or ICD-10-CM. In ICD-9-CM, it is coded with the same code as dermatitis factitia (artefacta) (698.4). APA initially recommended that this disorder be added to ICD-10-CM and given the same code as factitial dermatitis (L98.1). However, given that this is an OCD-related disorder, the NCHS officials at the recent revision conference preferred to temporarily assign this to the same F42 code as OCD with an exclusion of the factitial dermatitis (L98.1) code until a separate F42.x code can be assigned in 2015—this is to avoid a one-year trend increase in the L98.1 domain. Since ICD-10-CM codes are not yet in use, this issue will be resolved and posted when it is final.
Premenstrual dysphoric disorder (PMDD): This disorder is not listed in ICD-9-CM or ICD-10-CM. In ICD-9-CM, it is coded with the same code as premenstrual tension syndromes (625.4). APA initially recommended that PMDD be added to ICD-10-CM and given the same code as premenstrual tension syndrome (N94.3). However, given that premenstrual tension syndrome is generally considered a normal physiological state and not a mental disorder, the NCHS officials preferred that this receive a temporary code in the Depressive Disorders section (F33.xx) rather than in the N94.3 section. The decision on this code will be posted when final.
Additionally, APA petitioned for revisions to the ICD-10-CM listing for gender dysphoria in adolescents and adults, which is not a new disorder. The previous recommendation for the coding and listing of gender identity disorder in ICD-10-CM was to assign it the code of F64.1, which corresponds to dual-role transvestism.
Regier noted that this was an inappropriate designation, as transvestism and gender identity disorder are different phenomena. Further, DSM-5 has revised its conceptualization and terminology such that the disorder is now called gender dysphoria rather than gender identity disorder. APA is recommending that ICD-10-CM list this disorder as gender dysphoria in adolescence and adulthood, using the ICD-10 code that corresponds to transsexualism (F64.0).
“Although the 11th edition of ICD might not be approved by the World Health Organization until 2015 or later, the United States. is unlikely to adopt an ICD-11-CM for at least a decade or more following its release,” Regier said. “APA wants to ensure changes adopted in ICD-10-CM are as accurate and comprehensive as possible, given that this will be the ICD-CM code set in use in this country for the foreseeable future.” ■