HIPAA Rules Fail to Clarify Role of DSM-IV Criteria

The final federal rule for transmitting Medicare claims and information electronically has created uncertainty for psychiatrists and organizations providing mental health and substance abuse services. Health care professionals must comply with the final rule by October 16.

The final rule, published in the February 20 Federal Register, implements specific administrative simplification provisions of the 1996 Health Insurance Portability and Accountability Act (HIPAA). According to a legal analysis commissioned by APA last year, the 1996 law appears to allow only one designated medical diagnostic and procedure set.

“Our concern is that health care professionals will be allowed only to use the ninth edition of the International Classification of Diseases–Clinical Modification (ICD-9-CM) for mental and substance abuse disorders. The ICD-9-CM was published about 24 years ago and is completely outdated,” Darrel Regier, M.D., M.P.H., told Psychiatric News. He is the executive director of the American Psychiatric Institute for Research and Education and director of APA’s Division of Research.

APA has asked the Office of General Counsel in the Department of Health and Human Services to review the legal analysis and its recommendation that health care professionals be allowed to continue to use DSM-IV criteria for electronic transactions involving mental and substance abuse disorders, said Regier.

“The DSM-IV diagnostic criteria have been used informally to define ICD-9-CM diagnostic code numbers since 1980 when DSM-III was first adopted. Using DSM instead of the ICD-9 glossary of disorder definitions has been approved by the National Center for Health Statistics [NCHS] of the Centers for Disease Control and Prevention for over 20 years, and the DSM-IV criteria are designated in the draft of ICD-10-CM as the appropriate definitions of their diagnostic codes,” said Regier.

He continued, “However, the ICD-10-CM is not expected to be adopted in the United States until 2006 at the earliest. This means that the ICD-9-CM glossary would be the default official diagnostic criteria for mental disorders when [the rule] goes into effect in October.”

APA testified on the issue twice last year before the National Committee on Vital and Health Statistics Subcommittee on Standards and Security.

“We are still waiting as of March 31 for the general counsel to respond. The Center for Mental Health Services and NCHS share our concerns,” said Regier.

The text of the electronic transactions and code set rule is posted on the CMS Web site at www.cms.hhs.gov/hipaa/hipaa2. Also posted is the final rule for security standards regarding electronic transactions. Health care professionals have until April 21, 2005, to comply with that rule. ▪