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Here’s why your claims are being rejected

April 01, 2016

As I’ve said before, lack of compliance with the ICD-10 CM ultimately puts organizations at risk. In the past six months, I have been hearing reports that Medicare and Medicaid programs have been rejecting claims for certain diagnoses. It seems the common thread for these rejections is the utilization of certain unspecified diagnoses that are obtained directly out of the DSM-5 purple book.

What I am going to say next will likely be met with unhappiness: This action by the Centers for Medicare and Medicaid Services (CMS) is not a surprise, and CMS is exactly correct in its actions. Is this hard to hear, especially because your provider organization is losing money? Let me explain.

On October 1, 2015, all HIPAA-covered entities in the United States were mandated to transition to the ICD-10 CM and to follow all the ICD-10 CM guidelines and protocols. That’s it—straightforward and very simple. There is no other explanation.

You have to believe that the ICD-10 CM transition applies to you. We get into a quandary because the DSM series is deeply embedded in our group-think here in the United States. While historically it has not presented a problem for us when it comes to diagnosing and submitting codes on claim forms, it does now and therein lies the rub.

You can go back and read all the information on steps to take in order to be ICD-10 compliant in previous posts. For now, the more immediate issue has to do with how you rectify or mitigate risk for this current situation. Thinking trade organizations will help bring the revenues flowing back into your organization is insufficient, and frankly, this is a matter of federal policy, which is unlikely to budge anytime soon, nor should it.

Why problems will persist

While there are over 300 discrepancies between the two classification systems, the two most problematic issues thus far are post-traumatic stress disorder (PTSD) and schizophrenia.

  • Clinicians are only using the DSM-5 to obtain codes, not the ICD-10 CM Tabular Index.
  • DSM-5 diagnoses for PTSD and schizophrenia have been assigned an unspecified code: F20.9 Schizophrenia, Unspecified and F43.10, PTSD, Unspecified. There are several different diagnoses for schizophrenia and a few additional diagnoses for PTSD in the ICD-10-CM that provide the specificity CMS is appropriately mandating.
  • Some EHRs have only loaded the DSM-5 codes into their systems, thus not providing fully-complaint functionality in the systems.
  • Some provider entities are regulated to submit only DSM-5 diagnoses to counties for payment, only to find that downstream those diagnoses are a problem.
  • The persistent myth that ICD-series codes do not apply to certain providers and the idea that DSM is enough prevail.

Who is responsible for this?

According to the claim rejections many of you have been receiving, you are responsible. The IT system limitations fall on the shoulders of the vendor. We are all in this together, and the need to make it work is in the best interests of all stakeholders. If behavioral health is seeking parity and equality, the industry must be working towards full integration with the entire U.S. healthcare industry. This starts with training in our graduate schools, training current staff, and by providers using the federally-endorsed standardized language of ICD-10-CM. 

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