Your diagnostic codes are changing

Most professional psychologists are already using the World Health Organization's International Classification of Diseases (ICD) without even realizing it.

When a psychologist submits a diagnostic code drawn from the Diagnostic and Statistical Manual (DSM) to an insurer for reimbursement, that insurer receives the code as an ICD code, says Lynn Bufka, PhD, assistant executive director for practice research and policy in APA's Practice Directorate.

That's because the DSM-IV and the ICD-9-CM — the version clinically modified by the Centers for Disease Control and Prevention (CDC) for use in the United States — have been "harmonized" and so are very similar.

All that will change starting Oct. 1, when the United States will shift from the ICD-9-CM to the ICD-10-CM. The new version differs considerably from the DSM, with new codes, plus a new alphanumeric coding system to replace the old numeric system.

Some insurers have already announced they will no longer accept DSM codes for billing. And some say that could be a problem for professional psychologists, who worry that both psychologists already in practice and those still in training aren't prepared to make that transition.

The global standard

The ICD is the global clinical and research standard for both physical and mental health conditions, says Princeton, N.J., private practitioner Carol D. Goodheart, EdD, author of the forthcoming "A Primer for ICD-10-CM-Users: Psychological and Behavioral Conditions." The volume, which will be available in January, is the first in a series of APA books and resources designed to help psychologists make the transition to the ICD-10-CM.

As a World Health Assembly member state, the United States is required by treaty to use the ICD, Goodheart explains. (Clinicians outside the United States have already been using the ICD-10 since soon after it was published in 1990 and are now preparing to transition to the ICD-11, expected in 2015.)

What's more, the Health Insurance Portability and Accountability Act (HIPAA) requires the use of ICD diagnostic codes rather than DSM codes.

"All psychologists who offer health-care services, such as psychotherapy or initial evaluations, and who expect reimbursement from health insurers — or whose patients expect reimbursement from insurers — must use ICD codes," says Goodheart, adding that psychologists shouldn't confuse the ICD's diagnostic codes with the procedure codes known as the Current Procedural Terminology, or CPT, codes.

The ICD-10-CM expands the overall number of codes from about 14,000 to more than 68,000, says Goodheart. Of course, she adds, the ICD covers both mental and physical disorders, so most of those codes don't apply to psychologists. Most psychologists need only concern themselves with the chapter on mental and behavioral disorders, she says.

"I tell people not to be too daunted," says Goodheart, who offers workshops on the ICD to state, provincial and territorial psychological associations (SPTPAs).

The shift to the ICD-10-CM will help practitioners, says Goodheart. For one thing, she says, "the ICD-9-CM is obsolete." And while the basic categories psychologists tend to use will stay the same, she says, the number of codes available will expand. Those who specialize in substance use treatment, for example, will find a greatly expanded code set.

But clinicians aren't the ones who will benefit most from the transition, says Goodheart.

"The biggest change isn't necessarily going to be noticed by practitioners: The ICD-10-CM is a better fit for health information technology systems," she says. "Most of the benefit really is for public health monitoring, claims processing, payment systems development — that kind of thing."

Psychologists won't see big changes that benefit their patients and themselves until the roll-out of the ICD-11-CM, she says. That version will be much more clinically useful, she predicts. The new version will reflect the way clinicians around the world categorize mental and behavioral disorders and feature a more clinically intuitive architecture that will be easier to use, she says.

Training current and future practitioners

To prepare for these coming changes, professional psychologists should begin by familiarizing themselves with the ICD-10-CM codes, says Goodheart. The ICD-10-CM is available for free from the CDC website.

APA is working hard to ensure that current practitioners are ready, says Cynthia D. Belar, PhD, executive director of APA's Education Directorate.

"Through our Office of Continuing Education, we have developed partnerships with a lot of SPTAs, sending people to do workshops," says Belar. "Efforts are underway, and there will be more."

Preparing the next generation of practitioners is also key, says Belar. To help with that process, APA plans to make parts of Goodheart's Clinician's Corner webinar available to psychology doctoral and internship programs.

What's also needed is advocacy, says Elena J. Eisman, EdD, who left her position as executive director and director of professional affairs at the Massachusetts Psychological Association in December. Of particular concern is the fact that the current Examination for Professional Practice in Psychology (EPPP) doesn't include any ICD-related questions. As a result, she says, many psychology graduate training programs aren't teaching the ICD.

"Our position has been to assess what is being taught in programs rather than guide what is being taught," says Matt Turner, PhD, director of regulatory affairs at the Association of State and Provincial Psychology Boards (ASPPB), which administers the exam. "Because the vast majority of training programs have historically taught only the DSM, we have attempted to mirror current training."

That's not as big a problem as people suspect, Turner adds, pointing out that the current EPPP includes only a small number of items specifically related to the DSM. Plus, he says, ASPPB will consider adding ICD content to the exam should training programs shift toward teaching the ICD.

Psychology needs to push training programs to get trainees up to speed, while also pushing for the EPPP to include questions on the ICD, says Eisman. At the very least, she says, programs need to teach students to be "bilingual" when it comes to diagnostic systems.

"What's being taught needs to reflect what's needed," she says. "It's imperative that our graduates and current psychologists know the diagnostic schema for the ICD in order to stay viable in health insurance and to present the kind of authorization requests and claims forms that are going to be accepted."

Rebecca A. Clay is a writer in Washington, D.C.