Changes in the DSM-5 to autism spectrum disorder and other
conditions may affect providers' reimbursement for treating them,
because the new diagnosis codes do not correlate well with the
widely used system of billing codes.
The DSM focuses only on mental disorders. Health plans, however,
use diagnosis codes from the ICD (International Classification of
Diseases), which captures medical conditions, diseases, injuries
and mental conditions. Previous versions-but not DSM-5-have
correlated well with ICD codes.
In essence, mental health professionals use DSM to diagnose and
billing professionals use ICD to process claims-and previously, the
two codes matched. However, DSM-5 moves away from this previous
strong correlation with ICD codes, which are mandatory (per the
Health Insurance Portability and Accountability Act) for all
third-party electronic billing and reporting.
An example of diverging codes is the new DSM-5 "social
communication disorder," a code that does not appear in ICD at all.
A person with a social communication disorder may have features of
autism, but not enough to meet the new autism diagnostic standard.
Although ICD and DSM have always defined autism from slightly
different perspectives, the result was usually reasonably
consistent. The new social communication disorder definition,
however, does not align with ICD, and the ICD committee will have
to update the definition of pervasive developmental disorders and
autism in the next revision.
(ASHA, in its comments to the American Psychiatric Association
on DSM-5, indicated that social communication disorder is a
language disorder and should not be listed as a separate
The "communication disorders" codes pose another concern. Three
DSM-5 conditions-language disorder, speech sound disorder and
social communication disorder-have the same ICD-9 number: 315.39,
"articulation, phonological disorder. The corresponding codes in
ICD-10 (the updated version, which takes effect Oct. 1, 2014), are
differentiated to language disorder (F80.9), speech sound disorder
(F80.0) and social communication disorder (F80.89, "other
developmental disorders of speech and language"). Childhood-onset
fluency disorder is assigned 315.35 (ICD-9) and F80.81
No more Asperger's
One of the controversial changes in the DSM-5 groups all autism
subcategories into a single category-autism spectrum disorder-and
eliminates the diagnosis of Asperger's syndrome. ICD has not
indicated if it will adopt the DSM-5 description of autism spectrum
disorder, including the criteria parameters and the elimination of
the term "Asperger's."
According to information on the Autism Speaks website, "all individuals who currently
have a diagnosis on the autism spectrum, including those with
Asperger syndrome or PDD-NOS, will not lose their ASD diagnosis."
It also indicates that if an insurance plan currently provides
coverage for diagnosis and treatment of autism spectrum disorder,
there should be no disruption of coverage as a result of the DSM
change. The DSM-5, however, notes that "Individuals with a
well-established DSM-IV diagnosis of autistic disorder, Asperger's
... should be given the diagnosis of ASD. Individuals who have marked
deficits in social communication, but whose symptoms do not
otherwise meet criteria for ASD, should be evaluated for social
Some states are already addressing potential changes in
diagnoses. Connecticut introduced legislation-signed into law in
early June-that allows a person diagnosed with autism spectrum
disorder to retain the diagnosis, regardless of DSM changes.
ASHA will continue to monitor the impact of DSM-5 on coding
diagnoses, health plan payments and school services.