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DSM-5: Classification, Criteria, and Use

Transitioning to
DSM-5 and ICD-10-CM

Transitioning to DSM-5 and ICD-10-CM

William E. Narrow, M.D., M.P.H.


Acting Director, Division of Research,
American Psychiatric Association
Research Director, DSM-5 Task Force

July 8, 2014

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DSM-5: Classification, Criteria, and Use

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Transitioning to DSM-5 and ICD-10-CM
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Transitioning to DSM-5 and ICD-10-CM


Elinore McCance-Katz, M.D., Ph.D.
Chief Medical Officer
Substance Abuse and Mental Health
Services Administration

Transitioning to DSM-5 and ICD-10-CM

Darrel A. Regier, M.D., Ph.D.


Vice-Chair, DSM-5 Task Force
Senior Scientific Consultant &
Former Research Director (2000-2014),
American Psychiatric Association

DSM-5: Classification, Criteria, and Use

Topics and Content in this Activity

Brief history of DSM development and its


relationship to ICD
Classification structure of DSM-5
New DSM-5 disorders and codes
Integration of dimensional approaches to
diagnosis
DSM-5 and ICD-10-CM
Important insurance considerations for
clinicians
Copyright 2013. American Psychiatric Association.

ICD-7-8-9 and DSM-I-II

1900-1950 Influence of Emil Kraepelin,


Adolph Meyer, & Sigmund Freud

1955, 1965, 1977-ICD-7-8-9;track with DSM

1960: E. StengelWHO MH Advisor

1967-1972 US-UK study: demonstrated


need for explicit definitions to eliminate wide
national variations in diagnosis

1972: St. Louis Feighner Criteria16 Dx

1977: ICD-9Glossary Definitions


Copyright 2013. American Psychiatric Association.

ICD-9 and DSM-III

1978 Spitzer et al. modified and


expanded Feighner to create the
Research Diagnostic Criteria (RDC)
and SADS Interview

1980 DSM-IIIwent beyond glossary


of symptoms to explicit criteria sets
based on RDC

Copyright 2013. American Psychiatric Association.

DSM-5: Classification, Criteria, and Use

Impact of DSM-III on
International Collaboration
ADAMHA-WHO Collaboration 1980-1994
14 international Task Forces examined
approaches of national schools of
psychiatry
Copenhagen Conference, April 1982:
150 participants from 47 countries
Resulted in joint WHO/ADAMHA/APA
effort to develop DSM-IV and ICD-10; CIDI,
SCAN, and IPDE
Copyright 2013. American Psychiatric Association.

Conceptual Development of DSM


DSM-I
Presumed
etiology

DSM-5
Paradigm shift considered
(dimensional,
spectra,
developmental, culture,
impairment thresholds,
living document)

DSM-III
Paradigm shift
Explicit criteria
(emphasis on reliability
rather than validity)

DSM-II
Glossary
definitions

DSMIV
Requires clinically
significant distress
or impairment

DSM-III-R
Criteria broadened
Most hierarchies
dropped

Copyright 2013. American Psychiatric Association.

Perceived Shortcomings in DSM-IV

High rates of comorbidity

High use of NOS category

Treatment non-specificity

Inability to find specific laboratory


markers/ tests

DSM is starting to hinder research


progress

Copyright 2013. American Psychiatric Association.

DSM-5: Classification, Criteria, and Use

New Developments

Pressures to improve validity

Move toward an etiologically based classification

Are there data in these areas that can be helpful in


developing/changing/refining diagnoses?
Cognitive or behavioral science
Family studies and molecular genetics
NeuroscienceNIMH RDoC Program
Functional and structural imaging

Requires a Paradigm Shift


Neo-Kraepelinian (strict categorical) to
Spectrum Gene-Environmental Interaction-dimensional
Copyright 2013. American Psychiatric Association.

DSM-5 Classification Structure

DSM-5 Structure

Section I: DSM-5 Basics


Section II: Essential Elements: Diagnostic
Criteria and Codes
Section III: Emerging Measures and
Models
Appendix
Index

Copyright 2013. American Psychiatric Association.

DSM-5: Classification, Criteria, and Use

Section II:
Chapter Structure
A. Neurodevelopmental Disorders
B. Schizophrenia Spectrum and Other Psychotic
Disorders
C. Bipolar and Related Disorders
D. Depressive Disorders
E. Anxiety Disorders
F. Obsessive-Compulsive and Related Disorders
G. Trauma- and Stressor-Related Disorders
H. Dissociative Disorders
Copyright 2013. American Psychiatric Association.

Section II:
Chapter Structure
J. Somatic Symptom and Related Disorders
K. Feeding and Eating Disorders
L. Elimination Disorders
M. Sleep-Wake Disorders
N. Sexual Dysfunctions
P. Gender Dysphoria

Copyright 2013. American Psychiatric Association.

Section II:
Chapter Structure
Q. Disruptive, Impulse-Control, and Conduct Disorders
R. Substance-Related and Addictive Disorders
S. Neurocognitive Disorders
T. Personality Disorders
U. Paraphilic Disorders
V. Other Disorders
Medication-Induced Movement Disorders and Other
Adverse Effects of Medication
Other Conditions That May Be a Focus of Clinical
Attention
Copyright 2013. American Psychiatric Association.

DSM-5: Classification, Criteria, and Use

How many disorders are in Section II?

ChangesinSpecificDSMDisorderNumbers;
CombinationofNew,Eliminated,andCombined
Disorders
(netdifference=15)

SpecificMentalDisorders*
*NOS

DSMIV

DSM5

172

157

(DSM-IV) and Other Specified/Unspecified (DSM-5) conditions are counted


separately.

Copyright 2013. American Psychiatric Association.

NewandEliminatedDisordersinDSM5
NewDisorders

(netdifference=+13)

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.

Social(Pragmatic)CommunicationDisorder
DisruptiveMoodDysregulationDisorder
PremenstrualDysphoricDisorder(DSMIVappendix)
HoardingDisorder
Excoriation(SkinPicking)Disorder
DisinhibitedSocialEngagementDisorder(splitfromReactiveAttachmentDisorder)
BingeEatingDisorder(DSMIVappendix)
CentralSleepApnea(splitfromBreathingRelatedSleepDisorder)
SleepRelatedHypoventilation(splitfromBreathingRelatedSleepDisorder)
RapidEyeMovementSleepBehaviorDisorder(ParasomniaNOS)
RestlessLegsSyndrome(DyssomniaNOS)
CaffeineWithdrawal(DSMIVAppendix)
CannabisWithdrawal
MajorNeurocognitiveDisorderwithLewyBodyDisease(DementiaDuetoOther
MedicalConditions)
15. MildNeurocognitiveDisorder(DSMIVAppendix)

EliminatedDisorders
1.
2.

SexualAversionDisorder
PolysubstanceRelatedDisorder
Copyright 2013. American Psychiatric Association.

DSM-5: Classification, Criteria, and Use

CombinedSpecificDisordersinDSM5
(netdifference=28)
1.

LanguageDisorder(ExpressiveLanguageDisorder&MixedReceptiveExpressive
LanguageDisorder)

2.

AutismSpectrumDisorder(AutisticDisorder,AspergersDisorder,Childhood
DisintegrativeDisorder,&RettsdisorderPDDNOSisintheNOScount)

3.

SpecificLearningDisorder(ReadingDisorder,MathDisorder,&DisorderofWritten
Expression)

4.

DelusionalDisorder(SharedPsychoticDisorder&DelusionalDisorder)

5.

PanicDisorder(PanicDisorderWithoutAgoraphobia&PanicDisorderWithAgoraphobia)

6.

DissociativeAmnesia(DissociativeFugue&DissociativeAmnesia)

7.

SomaticSymptomDisorder(SomatizationDisorder,UndifferentiatedSomatoform
Disorder,&PainDisorder)

8.

InsomniaDisorder(PrimaryInsomnia&InsomniaRelatedtoAnotherMentalDisorder)

9.

HypersomnolenceDisorder(PrimaryHypersomnia&HypersomniaRelatedtoAnother
MentalDisorder)

10.

NonRapidEyeMovementSleepArousalDisorders(SleepwalkingDisorder&Sleep
TerrorDisorder)
Copyright 2013. American Psychiatric Association.

CombinedSpecificDisordersinDSM5(Continued)
(netdifference=28)
11.

GenitoPelvicPain/PenetrationDisorder(Vaginismus&Dyspareunia)

12.

AlcoholUseDisorder (AlcoholAbuseandAlcoholDependence)

13.

CannabisUseDisorder(CannabisAbuseandCannabisDependence)

14.

PhencyclidineUseDisorder(PhencyclidineAbuseandPhencyclidineDependence)

15.

OtherHallucinogenUseDisorder(HallucinogenAbuseandHallucinogenDependence)

16.

InhalantUseDisorder(InhalantAbuseandInhalantDependence)

17.

OpioidUseDisorder (OpioidAbuseandOpioidDependence)

18.

Sedative,Hypnotic,orAnxiolyticUseDisorder(Sedative,Hypnotic,orAnxiolyticAbuseand
Sedative,Hypnotic,orAnxiolyticDependence)

19.

StimulantUseDisorder(AmphetamineAbuse;AmphetamineDependence;CocaineAbuse;
CocaineDependence)

20.

StimulantIntoxication(AmphetamineIntoxicationandCocaineIntoxication)

21.

StimulantWithdrawal(AmphetamineWithdrawalandCocaineWithdrawal)

22.

Substance/MedicationInducedDisorders(aggregateofMood(+1),Anxiety(+1),and
Neurocognitive(3))

Copyright 2013. American Psychiatric Association.

ChangesfromNOSto
OtherSpecified/Unspecified
(netdifference=+24)

NOS(DSMIV) and Other


Specified/Unspecified
(DSM5)

DSMIV

DSM5

41

65

OtherSpecifiedandUnspecifiedDisordersinDSM5replaced
theNotOtherwiseSpecified(NOS)conditionsinDSMIVto
maintaingreaterconcordancewiththeofficialInternational
ClassificationofDiseases(ICD)codingsystem.Thisstatistical
accountingchangedoesnotsignifyanynewspecificmental
disorders.
Copyright 2013. American Psychiatric Association.

DSM-5: Classification, Criteria, and Use

Dimensional Approaches to Diagnoses:


Cross-Cutting Measures in
DSM-5 Section III

Optional Measurements in DSM-5

Assess patient characteristics not necessarily


included in diagnostic criteria but of high
relevance to prognosis, treatment planning and
outcome for most patients
In DSM-5, these include:
Level 1 and Level 2 Cross-Cutting Symptom
assessments
Diagnosis-specific Severity ratings
Disability assessment
May be patient, informant, or clinician completed,
depending on the measure
Copyright 2013. American Psychiatric Association.

Level 1 Cross-Cutting Symptom Measure

Referred to as cross-cutting because it calls


attention to symptoms relevant to most, if not
all, psychiatric disorders (e.g., mood, anxiety,
sleep disturbance, substance use, suicide)

Self-administered by patient
13 symptom domains for adults
12 symptoms domains for children 11+, parents
of children 6+
Brief1-3 questions per symptom domain
Screen for important symptoms, not for specific
diagnoses (i.e., cross-cutting)
Copyright 2013. American Psychiatric Association.

DSM-5: Classification, Criteria, and Use

Level 2 Cross-Cutting Measure

Completed when the corresponding Level 1


item is endorsed at the level of mild or
greater (for most but not all items, i.e.,
psychosis and inattention)
Gives a more detailed assessment of the
symptom domain
Largely based on pre-existing, well-validated
measures, including the SNAP-IV
(inattention); NIDA-modified ASSIST
(substance use); and PROMIS forms
(anger, sleep disturbance, emotional distress)
Copyright 2013. American Psychiatric Association.

Diagnosis-Specific Severity Measures

For documenting the severity of a specific


disorder using, for example, the frequency
and intensity of its component symptoms
Can be administered to individuals with:

A diagnosis meeting full criteria


An other specified diagnosis, esp. a clinically
significant syndrome that does not meet
diagnostic threshold

Some clinician-rated, some patient-rated

Copyright 2013. American Psychiatric Association.

DSM-5: Classification, Criteria, and Use

World Health Organization Disability


Assessment Schedule (WHODAS 2.0)

WHODAS 2.0 is the recommended, but not


required, assessment for disability
Corresponds to disability domains of ICF
Developed for use in all clinical and general
population groups
Tested worldwide and in DSM-5 Field Trials
36 questions, self-administered with clinician
review
For Adult Patients

Child version developed by DSM-5, not yet approved


by WHO
Copyright 2013. American Psychiatric Association.

DSM-5 and ICD-10-CM Coding

How are DSM-5 and ICD Related?


DSM-5 and the ICD should be thought of
as companion publications.
DSM-5 contains the most up-to-date
criteria for diagnosing mental disorders,
along with extensive descriptive text,
providing a common language for
clinicians to communicate about their
patients.

Copyright 2013. American Psychiatric Association.

DSM-5: Classification, Criteria, and Use

How are DSM-5 and ICD Related?


The ICD contains the code numbers used
in DSM-5 and all of medicine, needed for
insurance reimbursement and for
monitoring of morbidity and mortality
statistics by national and international
health agencies.
The APA is working closely with staff from
the WHO, CMS, and CDC-NCHS to
ensure that the two systems are maximally
compatible.

Copyright 2013. American Psychiatric Association.

How DID DSM-IV Handle ICD Coding?


DSM-IV used a single coding structure for
compatibility with ICD-9-CM diagnostic
codes.
Some DSM-IV diagnoses shared the same
ICD-9-CM code.

Copyright 2013. American Psychiatric Association.

DSM-5 and ICD Codes

DSM-5 and its ICD-9-CM codes became


effective in May 2013.
ICD-10-CM codes do not go into effect until
October 1, 2015.
ICD-9-CM codes are numerical and listed first.
ICD-10-CM codes are alphanumerical and
listed second, in parenthesis.

Copyright 2013. American Psychiatric Association.

DSM-5: Classification, Criteria, and Use

DSM-5 and ICD Codes


Codes accompany each criteria set, but
some codes are used for multiple disorders.

For example, hoarding disorder and obsessivecompulsive disorder share the same codes (ICD9-CM 300.3 and ICD-10-CM F42).
Because of this, the DSM-5 diagnosis should
always be recorded by name in the medical
record in addition to listing the code.

Copyright 2013. American Psychiatric Association.

DSM-5 and ICD Codes

For some disorders, unique codes are given for


subtypes, specifiers, and severity (e.g., major
depressive disorder).

For neurocognitive and substance/medicationinduced disorders, coding depends on further


specification.
Copyright 2013. American Psychiatric Association.

DSM-5 and ICD Codes

For neurocognitive and substance/medicationinduced disorders, coding depends on further


specification.
Clinicians should always check the bottom of the
diagnostic criteria box for coding notes, which
provide additional guidance as needed.

Copyright 2013. American Psychiatric Association.

DSM-5: Classification, Criteria, and Use

Inconsistencies in DSM and ICD


Code Names
New ICD codes could not be given to new
DSM-5 disorders; instead, these new
disorders were assigned the best available
ICD codes. The names connected with
these ICD codes sometimes do not match
the DSM-5 names.

For example, disruptive mood dysregulation


disorder is not listed in the ICD. The best ICD-9CM code available for DSM-5 use was 296.99
(other specified episodic mood disorder). For
ICD-10-CM the code will be F34.8 (other
persistent mood [affective] disorders).
Copyright 2013. American Psychiatric Association.

Inconsistencies in DSM and ICD


Code Names

APA has been working with CDC/NCHS and


CMS to include new DSM-5 terms in the ICD10-CM and will inform clinicians and
insurance companies when modifications are
made.
Because DSM-5 and ICD disorder names
may not match, the DSM-5 diagnosis should
always be recorded by name in the medical
record in addition to listing the code.
More examples of inconsistent naming are
provided in the following tables.
Copyright 2013. American Psychiatric Association.

New DSM-5 Diagnoses Code Issues


DSM-5 Disorder

ICD-9-CM ICD-9-CM Title


Code

Social (Pragmatic) 315.39


Communication
Disorder

Disruptive Mood
Dysregulation
Disorder

296.99

Premenstrual
625.4
Dysphoric
Disorder (from
DSM-IV appendix)

ICD-10-CM
Code

ICD-10-CM Title

Other
developmental
speech or
language
disorder

F80.89

Other
developmental
disorders of speech
and language

Other Specified
Episodic Mood
Disorder

F34.8

Other Persistent
Mood [Affective]
Disorder

Premenstrual
tension
syndromes

N94.3

Premenstrual
tension syndrome

Copyright 2013. American Psychiatric Association.

DSM-5: Classification, Criteria, and Use

New DSM-5 Diagnoses Code Issues


DSM-5 Disorder
Hoarding
Disorder

ICD-9-CM ICD-9-CM Title


Code
300.3
Obsessive
Compulsive
Disorders
698.4
dermatitis factitia
[artefacta]
307.51
bulimia nervosa

ICD-10-CM
Code
F42

ICD-10-CM Title
Obsessive
Compulsive Disorder

Excoriation (Skin
L98.1
factitial dermatitis
Picking) Disorder
Binge Eating
F50.2
bulimia nervosa
Disorder (from
DSM-IV Appendix)
Substance Use
Coding will be applied based on severity: ICD codes associated
Disorders
with substance abuse will be used to indicate mild SUD; ICD
codes associated with substance dependence will be used to
indicate moderate or severe SUD

Copyright 2013. American Psychiatric Association.

Changes to the Multiaxial System


DSM-5 combines all diagnoses onto a
single axis (previously Axes I-III).
Contributing psychosocial and
environmental factors (previously Axis IV)
or other reasons for visits are now
represented through an expanded
selected set of ICD-9-CM v codes and,
from the forthcoming ICD-10-CM, z and t
codes.

Copyright 2013. American Psychiatric Association.

Changes to the Multiaxial System


With Axis V eliminated, clinicians are no longer
required to use the Global Assessment of
Functioning (GAF) Scale.

GAF confounds symptom severity, risk of harm to


self or others, disability, and functioning and
combines into a single score.

Rather than use the single GAF score to


reflect multiple areas of concern, we have
unpacked the GAF such that these items can
be documented separately.

Risk of harm to self or others can be assessed


through APAs Clinical Practice Guidelines
(http://www.psychiatry.org/practice/clinical-practiceguidelines).
Copyright 2013. American Psychiatric Association.

DSM-5: Classification, Criteria, and Use

Changes to the Multiaxial System


An optional measure of disability is
provided in Section III of the manual (and
at www.psychiatry.org/dsm5) called the
World Health Organization Disability
Assessment Schedule 2.0 (WHODAS 2.0).

This is one of the most widely used disability


scales in medicine and is considered superior
to the GAF. Clinicians are highly encouraged,
though not required, to use the WHODAS 2.0
rather than the GAF.

Copyright 2013. American Psychiatric Association.

Changes to the Multiaxial System

For some diagnoses, functioning can also


be assessed using the diagnostic-specific
severity measures, which are available
online. (www.psychiatry.org/dsm5)

Copyright 2013. American Psychiatric Association.

How Should DSM-5 Diagnoses


Be Recorded?
Recording forms will vary by insurance
companies needs, and clinicians should
default to recording diagnoses according
to their clinics or insurance forms
requested format.
DSM-5 recommends a non-axial diagnosis
list format. For either inpatient or
outpatient settings, a principal diagnosis
should be listed, if one is present. If there
is not a mental disorder present, the vcode or z-code reason for visit should be
listed first.

Copyright 2013. American Psychiatric Association.

DSM-5: Classification, Criteria, and Use

How Should DSM-5 Diagnoses


Be Recorded?
In general, if an additional, non-psychiatric
medical condition is present, mental health
clinicians would first list the mental
disorder diagnosis, except when the other
medical condition is thought to be causing
the mental disorder.

In such cases, the medical condition should


be listed first (see Example III. on next slide).
Recording of disability will vary according to
insurance company requirements.

Copyright 2013. American Psychiatric Association.

Examples of How Diagnoses and


Conditions May Be Recorded

Example I.

Example III.
332.0 Parkinsons disease

296.22 Major depressive disorder,


single episode, moderate

294.11 Major
neurocognitive disorder
probably due to
Parkinsons disease, with
behavioral disturbance
V60.3 Problem related to
living alone

V62.4 Acculturation difficulty


V65.40 Other counseling or
consultation (nicotine use)

243 Congenital hypothyroidism

Example II.
307.1 Anorexia nervosa,
restricting subtype
300.02 Generalized anxiety
disorder
V62.3 Academic or educational
problem

Copyright 2013. American Psychiatric Association.

Important Insurance Considerations


When can DSM-5 be used for insurance
purposes?

Since DSM-5 is completely compatible with the


HIPAA-approved ICD-9-CM coding system now
in use by insurance companies, the revised
criteria for mental disorders can be used
immediately. However, the change in format from
a multiaxial system in DSM-IV-TR may result in a
brief delay while certain insurance companies
update their claim forms and reporting
procedures to accommodate DSM-5 changes.

Copyright 2013. American Psychiatric Association.

DSM-5: Classification, Criteria, and Use

Important Insurance Considerations


When can DSM-5 be used for insurance
purposes?

Although not all insurance companies have


transitioned to DSM-5 as of yet, some insurance
companies already require clinicians to use DSM5 diagnoses and codes. Clinicians will need to
check with their insurance carrier to determine
whether this is the case.
The expectation is that a full transition to DSM-5
by the insurance industry can be achieved by
October 1, 2015.

Copyright 2013. American Psychiatric Association.

DSM-5 Coding Updates


The DSM-5 Coding Update is now freely
available (PDF) and will be updated
regularly to reflect coding updates,
changes, or corrections, and other
information necessary for compensation in
mental health practice.
Available at:
http://dsm.psychiatryonline.org/DSM5Codi
ngSupplement

Copyright 2013. American Psychiatric Association.

Further Questions?

For more information about CMS acceptance of


DSM-5 visit their online FAQ at:
https://questions.cms.gov/faq.php?id=5005&faqId=
1817 This is being updated pending rule-making for
the delay in ICD-10-CM implementation

SAMHSA FAQ information is at:


http://store.samhsa.gov/shin/content/SMA144804/SMA14-4804.pdf

For more information about DSM-5 implementation,


a detailed Frequently Asked Questions document
can be found at www.dsm5.org
Copyright 2013. American Psychiatric Association.

DSM-5: Classification, Criteria, and Use