Jaburg Wilk


Behavioral Health Billing Alert

Categories: Healthcare, Article

new behaviorial health billing rules

Providers of behavioral health services should be aware that the fifth edition of the American Psychiatric Association's Diagnostic and Statistical Manual (DSM-5), released in May 2013 after more than ten years in preparation, contains references to International Classification of Diseases version 9 (ICD-9) codes, and not to the newer ICD-10 codes.  No publication date for a sixth revision of this Manual has been announced. 

For Medicare and other federally-funded healthcare programs, the date of implementation of the newer ICD-10 codes is October 1, 2015.  From that date forward, billing to Medicare, AHCCCS, and other federally-funded payers must use the ICD-10 codes.  At present, it is not clear whether major commercial payer plans and intermediaries will require ICD-10 coding.  However, maintaining two different diagnosis coding systems in a billing operation is not likely to be cost-effective.  Most, if not all, billing functions will need to migrate to ICD-10 once the Medicare requirement is implemented.

Most providers of behavioral health services typically use between 15 and 20 of the available ICD-9 codes to describe their patients' conditions.  By the common rule of thumb, these 15 to 20 ICD-9 codes will break out into between 150 and 200 ICD-10 codes.  Significantly, the nomenclature used in the ICD-10 code narrative descriptions is not in all cases identical to nomenclature used in the DSM-5 explanations or ICD-9 code narratives, so some interpretation of the DSM-5 guidance will be required to identify the appropriate corresponding ICD-10 code.  

crosswalk documents Many providers and their billing agents are working now to prepare "crosswalk" documents providing clear guidance to providers and coders in the context of their individual practice for what additional factual matters need to be considered and included in the patient record to support the assignment of a more fact-specific ICD-10 code.  Although generally one ICD-9 code should map to some discrete number of ICD-10 codes, with the differentiating factor being some fact or set of facts about the patient's history or condition that is different among the ICD-10 codes, care should be exercised to assure that the differentiating factors are clearly and correctly described in the "crosswalk."  The "crosswalk" explanation is necessarily a summary of the more detailed ICD-10 narratives, such that some information in the narrative may not appear in the "crosswalk" description.  For this reason, the "crosswalk" tool should be reviewed by a person highly conversant in the ICD-10 descriptors to assure material accuracy between the summary and the narrative.

Although the implementation date of ICD-10 has been delayed several times, there is no signal event between now and October 1st (such as a federal election) that gives any specific hope of further delay.  Anything could happen, but it seems prudent for behavioral health providers to seriously prepare now for implementation on October 1st.

About the author: Douglas O. Guffey is a healthcare attorney and partner at the Phoenix law firm of Jaburg Wilk. Doug has been practicing law for over 35 years, and spent thirteen years as the Executive Director of Sun Medical Management, LLC. Got a legal question for Douglas? Contact him here.

This article is not intended to provide legal advice and only relates to Arizona law. It does not consider the scope of laws in states other than Arizona.  Always consult an attorney for legal advice for your particular situation.