Insurance Implications of DSM-5

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), whose official publication date is May 22, has been developed to facilitate a seamless transition into immediate use by clinicians and insurers to maintain continuity of care. The revised manual represents a step forward in more precisely identifying and diagnosing mental disorders.

To help ensure ease of use, DSM-5 will continue to use statistical codes contained in the U.S. Clinical Modifications (CM) of the World Health Organization’s (WHO’s) International Classification of Diseases (ICD). The ICD-9-CM contains the internationally approved statistical codes for all medical diseases or disorders but does not contain detailed descriptions of how to diagnose these conditions. The APA Office of Healthcare Systems and Financing, along with APA’s DSM staff, will be meeting with representatives from the insurance industry in coming weeks to help ensure a seamless transition to use of DSM-5. The expectation is that the insurance industry’s transition to DSM-5 can be made by December 31.

Below are frequently asked questions that APA has received whose answers are pertinent to insurers and clinicians. Answers were prepared by the APA Office of Research.

When can DSM-5 be used for insurance purposes?

Since DSM-5 is completely compatible with the HIPAA-approved ICD-9-CM coding system now in use by insurance companies, the revised criteria for mental disorders can be used for diagnosing mental disorders immediately upon release. However, the change in format from a multiaxial system in DSM-IV-TR may result in a brief delay while insurance companies update their claim forms and reporting procedures to accommodate DSM-5 changes.

DSM-5 combines the first three DSM-IV-TR axes into one list that contains all mental disorders, including personality disorders and intellectual disability, as well as other medical diagnoses. Although a single-axis recording procedure was previously used for Medicare and Medicaid reporting, some insurance companies required clinicians to report on the status of all five DSM-IV-TR axes.

Contributing psychosocial and environmental factors or other reasons for visits are now represented through an expanded selected set of ICD-9-CM

V codes and, from the forthcoming ICD-10-CM, Z codes. These codes provide ways for clinicians to indicate other conditions or problems that may be a focus of clinical attention or otherwise affect the diagnosis, course, prognosis, or treatment of a mental disorder (such as relationship problems between patients and their intimate partners). These conditions may be coded along with the patient’s mental and other medical disorders if they are a focus of the current visit or help to explain the need for a treatment or test. Alternatively, they may be entered into the patient’s clinical record as useful information on circumstances that may affect the patient’s care.

DSM-5 contains both ICD-9-CM codes for immediate use and ICD-10-CM codes in parentheses. The inclusion of ICD-10-CM codes facilitates a cross-walk to the new coding system that will be implemented on October 1, 2014, for all U.S. health care providers and systems, as recommended by the Centers for Disease Control and Prevention’s National Center for Health Statistics (CDC-NCHS) and the Centers for Medicare and Medicaid Services (CMS). This feature will eliminate the need for separate training on ICD-10-CM codes for mental disorders that is now being offered for all other diseases/disorders by other medical societies and vendors to prepare for the 2014 implementation.

With the removal of the multiaxial system in DSM-5 , how will disability and functioning be assessed?

DSM-5 includes separate measures of symptom severity and disability for individual disorders, rather than the Global Assessment of Functioning (GAF) scale that combined assessment of symptom severity, suicide risk, and social functioning into a single global assessment. This change is consistent with WHO recommendations to move toward a clear conceptual distinction between the disorders contained in the ICD and the disabilities resulting from disorders, which are described in the International Classification of Functioning, Disability, and Health (ICF).

The World Health Organization Disability Assessment Schedule (WHO-DAS 2.0) is provided in Section III of DSM-5 as the best current method for measuring disability, and various disorder-specific severity scales are included in Section III and online. The WHO-DAS 2.0 is based on the ICF and is applicable to patients with any health condition, thereby bringing DSM-5 into greater alignment with other medical disciplines. While the WHO-DAS was tested in the DSM-5 field trials and found to be reliable, it is not being recommended by APA until more data are available to evaluate its utility in assessing disability status for treatment planning and monitoring purposes.

No. It is occasionally necessary to use the same code for more than one disorder. Because the DSM-5 diagnostic codes are limited to those contained in the ICD, some disorders must share codes for recording and billing purposes. For a few new disorders, such as disruptive mood dysregulation disorder, the only ICD-9-CM code available for DSM-5 was a “Not Otherwise Specified” (NOS) code from DSM-IV (mood disorder NOS 296.99). For ICD-10-CM the code will be F34.8, which is now “mood disorder, other specified.” APA will be working with CDC-NCHS and CMS to include new DSM-5 terms in the ICD-10-CM and will inform clinicians and insurance companies when modifications are made.

How are DSM-5 and ICD related?

DSM-5 and the ICD should be thought of as companion publications. DSM-5 contains the most up-to-date criteria for diagnosing mental disorders, along with extensive descriptive text, providing a common language for clinicians to communicate about their patients. The ICD contains the code numbers used in DSM-5 and all of medicine, needed for insurance reimbursement and for monitoring of morbidity and mortality statistics by national and international health agencies. APA works closely with staff from the WHO, CMS, and CDC-NCHS to ensure that the two systems are maximally compatible.

How is information from DSM-5 used?

DSM-5 is the handbook used by health care professionals in the United States and much of the world as the authoritative guide to the diagnosis of mental disorders. Clinicians use DSM-5 diagnoses to communicate with their patients and with other clinicians and to request reimbursement from insurance organizations. DSM-5 diagnoses may also be used by public health authorities for compiling and reporting morbidity and mortality statistics.

Another important role of DSM is to establish diagnoses for research on mental disorders. Only by having consistent and reliable diagnoses can researchers determine the risk factors and causes for specific disorders and determine their incidence and prevalence rates.

Can clinicians continue to use the DSM-IV-TR diagnostic criteria?

Clinicians may use DSM-5 in their practices when the manual is released May 22. However, there may be brief delays while insurance companies update their claim forms and reporting procedures to accommodate DSM-5 changes, and clinicians should use DSM-IV-TR diagnoses and codes when required by a specific company. Transition details are still being developed with CDC-NCHS, CMS, and private insurance agencies. APA is working with these groups with the expectation that a transition to DSM-5 by the insurance industry can be made by December 31, 2013.

As part of the transition to DSM-5, there will also need to be updates of questions in board certification examinations and quality assessments for medical-record reviews. APA will provide periodic updates of agreements with federal agencies, private insurance companies, and medical examination boards as they become available. ■

The CMS response to an FAQ about the relationship between DSM and ICD-9-CM is posted at https://questions.cms.gov/faq.php?id=5005&faqId=1817. This response will be updated to reflect the transition to DSM-5 as soon as it is released.