August 1, 2013 Features

DSM-5 Changes May Cause Billing Headaches

Providers may have a more difficult time linking new diagnosis codes to appropriate billing codes.

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.

Diverging codes

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 diagnosis.)

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 (ICD-10).

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 communication disorder."

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.  

Janet McCarty, MEd, CCC-SLP, is ASHA's private health plans advisor.

cite as: McCarty, J. (2013, August 01). DSM-5 Changes May Cause Billing Headaches. The ASHA Leader.


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