Trouble with timelines (1) DSM-5, ICD-10-CM, ICD-11 and ICD-11-CM

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Enmeshed classification systems

For medical insurance reimbursement, DSM-IV codes are converted to ICD-9-CM codes.

Since 2003, ICD-9-CM diagnostic codes have been mandated by HIPAA for all electronic reporting and transactions for third-party billing and reimbursement. For information on crosswalk of DSM-IV Codes to ICD-9-CM Codes see articles [2] [3] and [4].

There is a degree of concordance between DSM-IV categories and the Mental and behavioural disorders chapter of ICD-10 (Chapter V), from which ICD-10-CM has been developed.*

In 1978, WHO entered into a long-term collaborative project with the US Alcohol, Drug Abuse and Mental Health Administration (ADAMHA) aimed at facilitating further improvements in the classification and diagnosis of mental disorders and alcohol and drug related problems.

ADAMHA provided “generous support” for the activities preparatory to the drafting of ICD-10′s Mental and behavioural disorders chapter, promoting consultation between ICD-10 work groups and those working on the revision of APA’s DSM-III. Collaboration with the DSM-IV Task Force (chaired by Dr Allen Frances, MD) and the chairs of DSM-IV work groups allowed extensive exchange of views towards achieving compatibility between the texts [5].

Although DSM-IV and DSM-IV-TR were developed with the aim of compatibility with ICD-10, they include ICD-9-CM codes because the implementation of ICD-10-CM has been significantly delayed – by the time ICD-10-CM compliance becomes mandatory, DSM-IV will have been superseded by the next edition of the DSM, DSM-5.

ICD-10-CM is now essentially frozen until potentially beyond October 1, 2015, while DSM-5 remains subject to internal reviews, revision and refinement until the text is finalized and the manual put to bed, at the end of this year.

*The Mental and behavioural disorders chapter of ICD-10-CM will be known as “Chapter 5: Mental, Behavioral and Neurodevelopmental disorders (F01-F99)”

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APA shifts DSM-5 publication date

In December 2009, APA issued a press release announcing its intention to extend the DSM-5 drafting timeline and delay publication until May 2013.

“Extending the timeline will allow more time for public review, field trials and revisions…”

Evidently work on DSM-5 was behind running significantly behind schedule.

This extension, APA said, would also permit the DSM-5 to better link with the implementation of the ICD-10-CM codes for Medicare/Medicaid claims reporting and with the development of ICD-11:

“APA will continue to work with the WHO to harmonize the DSM-5 with the mental and behavioral disorders section of the ICD-11. Given the timing of the release of both DSM-5 and ICD-11 in relation to the ICD-10-CM, the APA will also work with the CDC and CMS to propose a structure for the U.S. ICD-10 CM that is reflective of the DSM-5 and ICD-11 harmonization efforts. This will be done prior to the time when the ICD-10-CM revisions are “frozen” for CMS and insurance companies to prepare for the October 1, 2013, adoption.”

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Darrel Regier lobbies for delay of partial code freeze

With the drafting of DSM-5 now running behind schedule and the prospect of a partial freeze on changes to ICD-10-CM codes and categories looming, there were barriers for APA for harmonization between the two systems.

In March 2010, APA sent Darrel Regier (American Psychiatric Association Research Director, Vice-chair DSM-5 Task Force) to the ICD-9-CM Coordination and Maintenance Committee Meeting to lobby for holding off the proposed code freeze to allow DSM-5 Task Force some time to catch up. ICD-9-CM C & M Committee is co-chaired by CDC and CMS.

Extract, transcript: March 9, 2010 ICD-9-CM Coordination and Maintenance Committee public meeting:

http://www.cdc.gov/nchs/data/icd9/Transcript3_9_2010.pdf

[...]

Pat Brooks, C0-Chairman: OK. Now, we’re going to move to probably one of the more controversial topics of the day, and that’s freezing of ICD-10 codes. I’m going to go through a summary of what’s happened so far, and then what (Donna) and I would like to hear is additional comments from the floor when we’re finished. And we would like for you after this meeting to send more comments…

…at our September 2009 Coordination and Maintenance Committee, we had an extensive discussion of whether or not we should freeze ICD-9 codes, and/or ICD-10 codes prior to the implementation of ICD-10 on October 1st, 2013…

…So, based on the comments we’ve gotten so far, we are recommending now that our last regular annual update to both ICD-9 and ICD-10 would be made on October 1st, 2011, so we’d be business as usual for 2011. Then, on October 1st, 2012, there would be only limited code updates for both ICD-9 and ICD-10 to capture new technologies and new diseases.

And by new technologies, we’re not going to totally restrict that just to people who are applying for new tech applications, that there’s some new surgery, some really important new procedure, then a handful of those codes we would consider too. And if there were new flu outbreak that’s only needed for CDC to capture, then, clearly, we need to have a handful of codes like that.

So, on October 1st, 2012, we’ll begin the annual process with dramatically reduced number of code updates. And then on October 1st, 2013, once again, the first year – this ICD-10 implemented, we would have a very limited number of new updates once again to capture new technologies and diseases.

We would continue to have our Coordination and Maintenance Committee meetings throughout this time, and any other issues that didn’t reach that mark after this group discussion on what’s a new technology and new procedure; this would be held until October 1st, 2014. And October 1st, 2014 would be our first regular update for ICD-10 from there ongoing…

…So I’ll now open up the floor to those here in the room to have their comments if they agree or disagree with the October 1st, 2011 last regular update.

Darrel Regier (American Psychiatric Association Research Director, Vice-chair DSM-5 Task Force): Good morning. I’m Darrel Regier from the American Psychiatric Association. And we are in the middle of a major revision of the diagnostic and statistical manual of mental disorders.

We have just released draft criteria on a website on February 10th at dsm5.org. And we’ll be having a field trial starting in July of this year. We’ll then have another revision based on field trial results going into a second revision or second field trial in July of 2011.

As a result, we will not have our final recommendations for the DSM-V probably until early 2011. So our clear recommendation would be to have the final freeze of the major classification for mental disorders, the chapter S* in this case for October 1st, 2012.

[*Ed: Transcriber error: "chapter 5" not "chapter S".]

The importance of this for us is that we had a complete conversion table (inaudible) as you will for DSM-IV and ICD-10 that was prepared back in about 1995 or so. So it’s been sitting, waiting, ready to go for ICD-10 for quite some time. Our expectation is that we will be working with the central office at WHO on the mental health division throughout this time. They, of course, are working on ICD-11, which they hope to implement or approve in 2014.

Our expectation though is that ICD-10-CM will be the procedure – will be the diagnostic code for this country probably for the next 20 years. Maybe not as long as 36 years as ICD-9-CM has been, but our plan is to really have concordance between the proposed ICD-11 major categories and disease names in agreement and harmonization with the DSM-V by about October of 2012.

So, that’s what we’re working toward. From the ICD standpoint, this would give them really a wonderful field trial for their ICD-11 if we introduced the mental health codes into the ICD-10-CM that essentially will be going into ICD-11. So, it’s a strange period of time with the revision of ICD-11 and now the revision of DSM-V being basically in synch.

What would be remarkably helpful is if we could basically hold on the firm freeze of the ICD-10-CM so that we could have this synchronization with DSM-V and then we would have a system that would be supportive of mental health diagnosis coding for probably a couple of decades.

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Dr Regier also attended the September 2010 Coordination and Maintenance meeting at which it was announced that CMS/CDC had decided to proceed with their recommendation to apply a partial code freeze on October 1, 2011:

Extract, transcript: September 15-16, 2010 ICD-9-CM Coordination and Maintenance Committee public meeting:

http://www.cdc.gov/nchs/data/icd9/Transcript91510Morning.pdf

Extract: Transcript Day One, morning session:

[...]

Your first question comes from the line of Pat King from the South Carolina Department of Mental Health, your line is open.

Pat King: Thank you for taking my call. What I was going to ask about is the DSM-4- TR codes that we use, is there – there’s not – is there a mapping available using those codes or do we have to rebuild with ICD-9 but we still use the DSM-4 codes?

Donna Pickett: I’m not aware that anyone is doing a mapping between DSM-4 and ICD-10-CM but there is someone in the audience who may be able to help with that question and then Dr. Darrel Regier over here from the American Psychiatric Association, and he is moving to the microphone.

Pat King: Thank you.

Dr. Darrel Regier: Hi, it’s Darrel over here from the APA. As you know, we are currently working on the DSM-5 and I’ve been in touch with Donna about actually trying to anticipate the DSM-5 changes in time for the ICD-10-CM and we’ve been working with the WHO Department of Mental Health and Substance Abuse that is also working on the ICD-11. So, we will have something ready to propose to Donna that would be coming in, probably in November at the earliest and certainly in January for any particular changes.

Now, in terms of a coding – kind of a crosswalk between the current DSM-4 and the ICD-10-CM, the ICD-10-CM essentially incorporates the DSM-4 names and already has in it the, I would say probably 99 percent of the translations that would be appropriate. We actually published an international version of the DSM-4 back in the early 1990s when ICD-10 was available, so that international colleagues could use the definitions and the DSM and apply them to the ICD-10.

So the crosswalk has essentially been ready since the early 1990s for the major codes and in the current ICD-10. Our hope is as I said, that we would be able to actually make a modification to that current ICD-10 for the ICD-10-CM implementation which takes place in October 1 2013, about four months after the May 2013 release of the IC – excuse me, DSM-5.

Donna Pickett: Thank you Dr. Regier. Were there any other questions online?

Operator: There are no further questions from the phone.

Donna Pickett: There is one more question, Dr. Friedman.

Dr. David Friedman: Thank you. I got a text from my association. They want to know why we’re going to ICD-10 and not going to ICD-11?

Donna Pickett: That’s always a fun question. OK, I see the – well, let me give you a little background on how ICD-10-CM is developed and how that would relate to an ICD-11. WHO (World Health Organization) in the past has released their published version of the ICD, after which it is evaluated by different member states including the U.S. to see if that version is actually detailed enough for what each country uses it for.

So for ICD-10, when it was released by WHO, we had a roughly two-year evaluation of ICD-10 to determine whether or not ICD-10 as published by WHO, would actually works for us here in the U.S. for all of the reasons we currently use it and no, it didn’t. And so we spent obviously, a number of years working on modifications to ICD-10-CM to make it useful for use in the U.S. A similar process would have to be followed for ICD-11.

And while I know they’re looking to make it more expansive, at its core, it’s still primarily a mortality based classification which doesn’t work for all of the morbidity applications that we would need here in the U.S. for administrative financial transactions, quality benchmarking, statistical purposes, NCHS is a statistical agency. So the number of purposes that a clinical modification would be used for in the U.S., ICD-11 would have to be evaluated for that as well.

Now, the current timetable I believe, for ICD-11 is 2014 to the World Health Assembly, which basically means it wouldn’t roll out for another two years after that. If you were to wait and try to continue to use a very flawed ICD-9-CM in anticipation of an ICD-11, which still might need clinical modifications, say here in the U.S., I can stand here and tell you that there is nothing that I could continue to do to ICD-9-CM to make it useful for all the purposes that it’s currently used for.

But we will be guided by what WHO is doing, the U.S. does participate in that work, the North American Collaborating Center for ICD and ICF is housed at NCHS. So we will be working closely with WHO in the formation of what is in ICD-11, but will also give us a benefit of seeing what may be going into ICD-11 that could find its way into ICD-10-CM simultaneously.

APA posted its second draft of DSM-5 for public review on May 4, 2011. At the same time, it also published a revised Timeline from which all references to harmonization with ICD-11 and ICD-10-CM in the version of the Timeline that had stood prior to that date were redacted.

With slipping timelines, a partial code freeze and the prospect of no revisions to ICD-10-CM until after October 1, 2014, (now more likely October 1, 2015) – APA missed the boat.

In a June 2011 presentation to the International Congress of the Royal College of Psychiatrists, APA President, John M. Oldham, MD, MS, spoke of “Negotiations in progress to ‘harmonize’ DSM-5 with ICD-11 and to ‘retro-fit’ these codes into ICD-10-CM” and that DSM-5 would need “to include ICD-10-CM ‘F-codes’ in order to process all insurance claims beginning October 1, 2011.”

Concluded on Page 3

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