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ICD and DSM coding compliance will be important in 2020 and beyond

November 04, 2016

On October 1, the grace period for allowing providers to submit “less-than specific” codes ran out. If you recall, when ICD-10-CM went live in 2015, the federal government gave providers a transitional year to adjust to the shiny new code set, get educated and hone their skills at making specific diagnoses.

All is well, right? Not quite.

Despite the shift to ICD-10-CM, there are still providers who do not realize that the DSM-5 does not constitute a code book for the purposes of getting paid. More concerning is that solely using the DSM-5 will result in a less-than-complete integrated clinical diagnostic picture of a client. Moving forward, providers will need to be able to easily extract integrated information from the EHR if they are to survive new reimbursement models such as the Medicare Access and CHIP Reauthorization Act (MACRA).

Consider the following:

  • How is medical information (such as comorbid conditions) captured in your EHR so that it can be extracted and transmitted with interoperable data exchange? Historically, we put this on Axis III, but that is now gone. Many provider organizations are simply no longer tracking medical inputs because it requires some level of code assignment. A text-narrative mention in the record may not communicate to other healthcare entities the critical information needed for a comprehensive snapshot of a case.
  • Emergency Departments are now required to track incidents of self-harm for reporting purposes. Emerging Certified Community Behavioral Health Clinics will also have to report on incidents of self-harm. The most effective way to track this in an EHR is to utilize the X-codes, “Intentional Self-Harm.” With this attention to suicidal and self-harm behaviors, it is likely that all behavioral health providers will need to capture this data as a discreet code in order to easily track these statistics.
  •  While helpful, some DSM-5 diagnoses have specifiers that are written words, not actual code numbers. The resulting unstructured data in an EHR is not easily extracted, but a code number can be. Some payers are looking for specific ICD-10-CM codes for a client’s condition, not a written narrative that needs to be explained upon further review.

Many providers have had a couple rounds of behavioral health reimbursement denials in the last year. The situation typically leaves the organization wondering what happened because they feel confident that the submitted claim with a code from the DSM-5 is correct. Even today, some EHR systems in our market do not contain the entire set of available ICD-10-CM diagnosis codes in the drop-downs. This leaves the clinician and provider organization at risk, not just for misdiagnosing, but also for failure to follow HIPAA and other related mandates.

What is a provider organization to do? It is imperative for value-based reimbursements and population-health that the ICD-10-CM coding and documentation guidelines are followed. First, find all the available diagnosis codes in the 2017 ICD-10-CM Tabular Index. In 2019 and beyond, eligible social workers and psychologists under certain MACRA rules may experience payment reductions of 4% if they do not report on certain metrics inclusive of medical conditions and self-harm. By 2022, the payment reduction penalty is 9%. Many metrics are easily calculated and extracted with the right coding of these conditions in your EHR. By just taking this step of using the Tabular Index and coding properly, behavioral health providers will position themselves well in the healthcare system.

The ICD-10-CM system is large and complicated. Graduate schools need to start training students in the ICD series, and provider organizations need a crash course now. Everyone has just been assigned homework, so enjoy your studies.

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