November 1, 2013
by admindxrw
Update: My submission on behalf of Dx Revision Watch can be read here.
The American Psychiatric Association (APA) has proposed the following DSM-5 disorders for inclusion in the forthcoming ICD-10-CM (Pages 32-44, September 2013 Diagnosis Agenda):
Binge eating disorder (BED);
Disruptive mood dysregulation disorder (DMDD);
Social (pragmatic) communication disorder;
Hoarding disorder;
Excoriation (skin picking) disorder;
Premenstrual dysphoric disorder (PMDD)
Additionally, APA has petitioned for revisions to the ICD-10-CM listing for gender dysphoria in adolescents and adults, which is not a new disorder.
On Page 45 and 46 of the Agenda, under Additional Tabular List Inclusion Terms for ICD-10-CM a number of other additions and changes to specific Chapter 5 F codes are being proposed, including the insertion of Somatic symptom disorder (SSD) and Illness anxiety disorder.
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A final reminder of the deadline for comments and objections in relation to Somatic symptom disorder
Q: When do objections need to be in by and where should they be sent?
A: Submit objections via email by November 15 to Donna Pickett, CDC: nchsicd9CM@cdc.gov
Q: Can anyone submit objections?
A: Yes. And from as many patient, professional and advocacy groups as possible, particularly from the U.S. but also international objections. Although this concerns potential changes to the draft of the U.S. specific ICD-10-CM there may be implications for ICD-11.
Q: What is being proposed?
A: The American Psychiatric Association has requested 6 new DSM-5 disorders for consideration for inclusion in the forthcoming ICD-10-CM via the September 18-19, 2013 ICD-9-CM Coordination and Maintenance Committee meeting.
APA’s rationales for these requested additions, the coding proposals and timings are set out on Pages 32 thru 44 of the September meeting Diagnosis Agenda.
But on Pages 45-46, under “Additional Tabular List Inclusion Terms for ICD-10-CM”, a further 17 proposals and changes are listed for consideration for addition to the Mental and behavioral disorders F codes.
These include the addition of the new DSM-5 categories, Somatic symptom disorder (SSD) and Illness anxiety disorder, as inclusion terms, under the ICD-10-CM Somatoform disorders section, thus:
Source: September 2013 Diagnosis Agenda, Page 45
The Diagnosis Agenda can be downloaded here: http://www.cdc.gov/nchs/data/icd/icd_topic_packet_sept_181913.pdf
Q: Is “Somatic symptom disorder” being proposed to replace several existing ICD-10-CM Somatoform disorders categories and is a unique new code proposed to be assigned to SSD?
A: No, not in the proposal as it stands in the Diagnosis Agenda document.
The proposal is to add SSD as an inclusion term under F45.1 Undifferentiated somatoform disorder. This is the ICD-10-CM code to which SSD is cross-walked in the DSM-5.
Illness anxiety disorder is being proposed as an inclusion term under F45.21 Hypochondriasis. This is the ICD-10-CM code to which Illness anxiety disorder is cross-walked in the DSM-5.
Q: What should I include in my objection?
A: Responders are being asked by NCHS/CMS to consider the following: Whether you agree with a proposal, disagree (and why), or have an alternative proposal to suggest.
Responders are also being asked to comment on the timing of those proposals that are being requested for approval for October 2014: Does a specific proposal for a new or changed Index entry and Tabular List entry meet the criteria for consideration for implementation during a partial code freeze [6] or should consideration for approval be deferred to October 2015?
And separately, and where applicable, comment on the creation of a specific new code for the condition effective from October 1, 2015. (This is not applicable in the case of SSD or Illness anxiety disorder.)
• Since no timing has been specified for the proposed insertion of the requests on Pages 45-46, I suggest stating that as a poorly validated disorder construct, SSD does not meet NCHS/CMS criteria for “new diseases/new technology procedures, and any minor revisions to correct reported errors in these classifications” and should not be considered for approval during a partial code freeze.
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On Day Two of the meeting, APA’s Darrel Regier presented 7 proposals for additions or changes, discussed APA’s rationales for each of these requests, in turn, and fielded any resulting questions or comments from the floor or from the meeting chairpersons.
Rationales, references, specific coding proposals for addition as inclusion terms in October 2014 (and subsequent code modifications in those cases where a unique new ICD code is proposed to be created for the term effective from October 2015) are also set out in the Agenda document (from Page 32).
But there was no presentation on behalf of APA, or by representatives of NCHS or CMS, or by anyone else for the specific proposal to add Somatic symptom disorder (SSD) and Illness anxiety disorder as inclusion terms under the ICD-10-CM Somatoform disorders.
No rationales for their inclusion or references to scientific evidence to support the validity of these new DSM-5 constructs have been published in the Diagnosis Agenda and there was no discussion of these two proposals during the course of the meeting.
The requesters of the proposals set out on Pages 45-46 are not identified, so it is unclear whether these “Additional Tabular List Inclusion Terms” are being proposed by APA or by NCHS/CMS.
• I suggest you comment in submissions on the absence from both the Agenda document and the meeting presentations of rationales and references to enable proper public scrutiny, consideration and informed responses to the proposed inclusion of these two terms.
All that was said about the list of proposals on Pages 45-46 was the following, after Dr Regier had wrapped up his own presentation and handed the podium back to the Co-Chair:
[Unofficial transcription from videocast] Donna Pickett (CDC):
“…And just to complete the package, there are other Tabular List proposals that appear on Page 45 and 46 that we would also invite your comments on. And again, with some of the terminology changes that Dr Regier has described the intent here is to make sure that if those terms are being used, that they do have a home somewhere within ICD-10-CM to facilitate people looking these up. So we invite comments. We’re showing the Tabular List proposed changes; however, there obviously would be associated Alphabetic Index changes with that which we didn’t show just to keep the package a little bit smaller.”
• You might also consider quoting the APA’s disturbing DSM-5 field trial data (see March 2013 BMJ commentary by Prof Allen Frances for data).
• Or quote the SSD work group’s recognition of the shaky foundations and lack of scientific robustness for its new DSM-5 construct:
In its recent paper: Somatic Symptom Disorder: An important change in DSM, the SSD work group acknowledges the “small amount of validity data concerning SSD” and that much “remains to be determined” about the utility and reliability of the specific SSD criteria and its thresholds when applied in busy, general clinical practice, and there are “vital questions that must be answered.” [7]
• There is no body of published research on the epidemiology, clinical characteristics or treatment of the APA’s Somatic symptom disorder construct.
• There is a paucity of rigorous evidence for the validity, safety, reliability, acceptability and utility of the SSD construct when applied to adults and children in diverse clinical settings and across a spectrum of health and allied professionals.
• NCHS/CMS has insufficient scientific basis for the approval of SSD as a valid new disorder construct for inclusion within ICD; has published no independent field trial data and provided no rationale to inform public responses.
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Why is it important to submit objections?
If SSD is inserted as an inclusion term to an existing code in ICD-10-CM this may leverage the future replacement of several existing ICD-10-CM Somatoform disorders categories with the SSD construct, to more closely mirror DSM-5.
Inserting SSD as an inclusion term into ICD-10-CM may make it easier for ICD-11 to justify its proposal for a Bodily distress disorder to replace several existing ICD-10 Somatoform disorders categories. Though BDD may not mirror SSD exactly, it is anticipated to incorporate SSD’s characteristics and thereby facilitate harmonization between ICD-11 and DSM-5 disorder terminology.
As set out many times during the three DSM-5 stakeholder reviews and in several papers published earlier this year with Prof Allen Frances, DSM-5 SSD has highly subjective and loose, easily met criteria.
A mental health diagnosis of SSD can be applied as a “bolt-on” to any chronic medical diagnosis – to patients with cancer, diabetes, heart disease, MS, angina, ME and CFS, IBS, FM, chronic pain conditions. It can be applied to adults and children (or to the caregivers of children with chronic illnesses).
SSD may become the dustbin diagnosis into which those with persistent, “medically unexplained” somatic (bodily) symptoms will be shovelled. Patients with rare or hard to diagnose illnesses may find themselves mislabelled with SSD.
Implications for the potential impact on patients for an additional diagnosis of SSD are set out (about half way down the page) in my report Somatic Symptom Disorder could capture millions more under mental health diagnosis and in copies of submissions to the three DSM-5 stakeholder review periods, collated on this site.
Also in Mary Dimmock’s 2012 SSD Call to Action materials.
There is a now a copy of the 20 March, 2013 BMJ commentary “The new somatic symptom disorder in DSM-5 risks mislabeling many people as mentally ill” by Prof Allen Frances (with Suzy Chapman) on the NAPPS Skills (Northern Association for Persistent Physical Symptoms) site (Vincent Deary’s group) in this PDF.
If you’ve not already done so, please get an objection in before November 15.
And please alert all contacts, advocates, patient groups and professionals to the November 15 deadline and the need for input and objections.
Further information:
1 Crazy Like Us: How the U.S. Exports Its Models of Illness – DSM-5 is Americanizing the world’s understanding of the mind Christopher Lane, Ph.D. in Side Effects, October 9, 2013
2. Dx Revision Watch: APA petitions CMS for additions to ICD-10-CM: Deadline for public comment and objections November 15: http://wp.me/pKrrB-3tq
3. Dx Revision Watch: Videos and meeting materials: September 18- 19 ICD-9-CM Coordination and Maintenance Committee meeting: http://wp.me/pKrrB-3tV
4. Article: ICD Codes for Some DSM-5 Diagnoses Updated, Mark Moran, Psychiatric News, October 07, 2013:
http://psychnews.psychiatryonline.org/newsarticle.aspx?articleID=1757346
5. ICD-9-CM/PCS Coordination and Maintenance Committee Meeting September 18-19, 2013
September C & M meeting Diagnosis Agenda Proposals PDF document [PDF – 342 KB]
http://www.cdc.gov/nchs/data/icd/icd_topic_packet_sept_181913.pdf
6. Partial Freeze of Revisions to ICD-9-CM and ICD-10-CM/PCS
7. Somatic Symptom Disorder: An important change in DSM. Dimsdale JE, Creed F, Escobar J, Sharpe M, Wulsin L, Barsky A, Lee S, Irwin MR, Levenson J. J Psychosom Res. 2013 Sep;75(3):223-8. Epub 2013 Jul 25.
dx revision watch 
Next meeting of ICD-10-CM Coordination and Maintenance Committee is March 19-20, 2014
November 16, 2013 by admindxrw
Post #282 Shortlink: http://wp.me/pKrrB-3xE
The deadline for receipt of public submissions in response to proposals for updates and changes to ICD-10-CM diagnosis and procedure codes presented at the September 18-19, 2013 meeting of the ICD-9-CM Coordination and Maintenance Committee has now closed.
In 2014, this advisory Committee, which is co-chaired by NCHS and CMS, will be known as the ICD-10-CM Coordination and Maintenance Committee, as there will be no further updates of ICD-9-CM.
A done deal?
Proposals submitted on behalf of the American Psychiatric Association (APA) and presented at the meeting by APA’s Research Director, Darrel Regier, MD, can be found from Page 32 of the Diagnosis Agenda. Additional proposals for inclusion of new DSM-5 disorder terms within ICD-10-CM Chapter 5 Mental and behavioral disorders can be found on Pages 45-46.
The Summary of the September meeting diagnosis presentations can be found here. Links for the four videocasts of the meeting’s two day proceedings are listed in this Dx Revision Watch post and the Meeting Materials are here.
The Timeline for ICD-9-CM (for the remainder of its life) and for ICD-10-CM is set out from Page 3 of the Diagnosis Agenda.
Some diagnosis proposals at the September 18-19, 2013 meeting were requested for October 2014 implementation and some for 2015 implementation. I shall update this site when the outcomes of the various proposals are published, next year.
There is a lack of clarity over which body has requested the addition of Somatic symptom disorder (SSD) and Illness anxiety disorder as inclusion terms to existing ICD-10-CM codes. It isn’t clear whether these two additional DSM-5 constructs have been proposed for inclusion in ICD-10-CM by the APA or by the NCHS/CMS Committee – if the latter, should we assume these two proposals already have the support of NCHS?
Given APA’s determination to achieve harmonization between the two systems, the outcome of its proposals to insert a handful of new DSM-5 disorders into ICD-10-CM may already be a done deal between APA and NCHS: the Director of NCHS may not need much persuasion to ratify their retrofitting into ICD-10-CM.
Loss of public trust and confidence
If NCHS is planning to rubber stamp insertion into ICD-10-CM of DSM-5’s poorly validated Somatic symptom disorder in response to APA diktat, having conducted no field testing and in the absence of a body of supportive evidence for SSD’s clinical relevance, safety and utility, and with disregard for a high level of public concern, what confidence can the public have that this federal agency is meeting its duty of care towards patient populations and towards the clinicians and allied health professionals who may deploy this proposed new ICD term, in its ethics, integrity and methods and for upholding standards of scientific rigour?
APA may re-present proposals next year
If APA is unsuccessful with any of the additions requested via the September meeting, it is possible that the organization may re-present proposals or modified proposals at the next C & M Committee meeting, scheduled for March 19-20, 2014. There are also other new DSM-5 disorders or changes that APA might potentially propose for incorporation into ICD-10-CM at the March 2014 or the September 2014 meeting, or at some later point.
Only a brief public submission period for March 2014 meeting
March 19-20, 2014 meeting
The deadline for Requestors to submit proposals for consideration for the March meeting agenda is January 17, 2014.
The draft agenda will be posted in February 2014.
Registration is required for those wishing to attend the meeting. Register online between on February 14 – March 14.
The two day meeting is scheduled for March 19 – 20.
Note: the deadline for receipt of comments on the March 19-20, 2014 meeting proposals for both procedure and diagnosis codes and changes is given as April 18. So instead of a couple of months for stakeholder responses, it appears there will only be four weeks or so in which to prepare and submit comments or objections.
I will post the Diagnosis Agenda for the March 2014 meeting as soon as it becomes available and links for the videocasts of the proceedings after the meeting has taken place. (Videocasts now substitute for written transcripts of meeting proceedings.)
Extracts from the Timeline that relate to the publication of additions and changes for ICD-10-CM:
April 2014 Notice of Proposed Rulemaking to be published in the Federal Register as mandated by Public Law 99-509. This notice will include references to the complete and finalized FY 2015 ICD-10-CM diagnosis and ICD-10-PCS procedure codes. It will also include proposed revisions to the MS-DRG system based on ICD-10-CM/PCS codes on which the public may comment. The proposed rule can be accessed here.
June 2014 Final addendum posted on web pages as follows:
Diagnosis addendum – http://www.cdc.gov/nchs/icd/icd10cm.htm
Procedure addendum – http://cms.hhs.gov/Medicare/Coding/ICD10/index.html
October 1, 2014 New and revised ICD-10-CM and ICD-10-PCS codes go into effect along with DRG changes. Final addendum posted on web pages as follows:
Diagnosis addendum – http://www.cdc.gov/nchs/icd/icd9cm_addenda_guidelines.htm
Procedure addendum – http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/addendum.html
November 2014 Any new ICD-10 codes required to capture new technology that will be implemented on the following April 1 will be announced. Information on any new codes to be implemented April 1, 2015 will be posted on the following websites:
http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/addendum.html
http://www.cdc.gov/nchs/icd/icd9cm_addenda_guidelines.htm
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Filed under American Psychiatric Association (APA), Darrel Regier, Diagnostic classification, DSM-5, ICD-10-CM, ICD-11, MUS, Somatic Symptom Disorder, Somatoform Disorders, WHO Collaborating Centre Tagged with american psychiatric association, dsm-5, icd-10-cm, icd-11, illness anxiety disorder, institute of psychiatry, NCHS, public comment, somatic symptom disorder, somatoform disorders