by Wyn Staheli
March 26th, 2015
This FAQ article was created to address some commonly asked questions about DSM coding and clear up some common misconceptions. The Diagnostic and Statistical Manual for Mental Disorders (DSM) is the standard classification of mental disorders used by mental health professionals in the United States. It is generally accepted as the authoritative guide for the diagnosis of mental disorders.
Find-A-Code Feature Note: Find-A-Code includes the Diagnostic Criteria created by the World Health Organization (WHO) for those with a Professional or higher subscription. These criteria have been recommended by some organizations and can provide guidance on assessing patient symptoms to arrive at a diagnosis. They can be viewed by clicking on the [WHO Diagnostic Criteria] tab found below the code description (ICD-10-CM Chapter 5 only).
Q: Do I use DSM-5 codes when submitting insurance claims?
A: The American Psychiatric Association states that "DSM-5 and the ICD should be thought of as companion publications." DSM is not an official HIPAA code set - ICD-10-CM is the official HIPAA approved diagnostic code set for billing. Currently, DSM code numbers are based on ICD code numbers. If you want to be paid, you need to bill from the official code set - ICD-10-CM. See the questions below for more about DSM codes versus DSM criteria. They are two entirely separate things!
It is up to the provider to understand the specific requirements for each payer. Some may say that you may use DSM-5 codes because they are closely correlated to ICD-10-CM. Others may require providers to use the most accurate ICD-10-CM code to describe the condition. Keep in mind that in order to avoid allegations of improper billing, providers MUST adhere to the requirements of the payer.
We stated that they are "closely correlated" because the problem that we have had in the past, and continue to have, is that ICD-10-CM code descriptions and DSM criteria do not always match one another. For example, as the ICD-10-CM code set is revised, sometimes a single code is expanded into several codes. When this happens, the code listed in a DSM book no longer is the most accurate code according to HIPAA standards. Providers need to be aware of any changes to the official HIPAA code set to avoid billing and reimbursement problems.
Q: Can clinicians use DSM codes?
A: The Center for Medicare and Medicaid Services (CMS), answers this question in FAQ1817 which says:
The Introduction to the DSM-IV indicates that the DSM-IV is “fully compatible” with the ICD-9-CM. The reason for this compatibility is that each diagnosis listed in the DSM-IV is “crosswalked” to the appropriate [ICD-10-CM] code. The DSM-IV is not a HIPAA adopted code set and may not be used in HIPAA standard transactions. It is expected that clinicians may continue to base their diagnostic decisions on the DSM-IV criteria, and, if so, to crosswalk those decisions to the appropriate [ICD-10-CM] codes. In addition, it is still perfectly permissible for providers and others to use the DSM-IV codes, descriptors and diagnostic criteria for other purposes, including medical records, quality assessment, medical review, consultation and patient communications.
Q: Can I still use DSM-IV diagnostic criteria, even though DSM-IV (DSM-5) has not been adopted as a HIPAA code set?
A: CMS, who oversees HIPAA has stated the following (emphasis added):
The basic purpose for adopting code sets under HIPAA is to standardize the ‘data elements' used in the electronic processing of certain administrative and financial health care transactions. While the patient's diagnosis is a data element used in such transactions, the criteria considered by the clinician in reaching a diagnosis are not. Practitioners are free to use the DSM-IV diagnostic criteria—or any other diagnostic guidelines—without any HIPAA-related concerns.
Notice that this statement only refers to "criteria". Yes, use the criteria to reach a clinically appropriate diagnosis, but CMS and most payers require that the diagnosis code set for billing is ICD-10-CM.