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DSM-5: Classification, Criteria, and Use
Transitioning to DSM-5 and ICD-10-CM
William E. Narrow, M.D., M.P.H.Acting Director, Division of Research,
American Psychiatric AssociationResearch Director, DSM-5 Task Force
July 8, 2014
Transitioning to DSM-5 and ICD-10-CM
Webinar Housekeeping
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DSM-5: Classification, Criteria, and Use
In order to claim CME credit for participation in this webinar please visit www.APAeducation.org and enroll in the Transitioning to DSM-5 and ICD-10-CM course.
A recording of todays webinar will also be available one-hour after the live broadcast on www.APAeducation.org.
Webinar Housekeeping
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
Transitioning to DSM-5 and ICD-10-CM
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DSM-5: Classification, Criteria, and Use
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
Topics and Content in this Activity
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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
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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
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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
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Conceptual Development of DSM
DSMIVRequires clinically significant distress
or impairment
DSM-III-RCriteria broadened
Most hierarchiesdropped
DSM-IIIParadigm shiftExplicit criteria
(emphasis on reliability rather than validity)
DSM-IIGlossary definitions
DSM-IPresumed
etiology
DSM-5 Paradigm shift considered
(dimensional, spectra,
developmental, culture, impairment thresholds,
living document)
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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
Perceived Shortcomings in DSM-IV
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DSM-5: Classification, Criteria, and Use
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 scienceFamily studies and molecular geneticsNeuroscienceNIMH RDoC ProgramFunctional and structural imaging
Requires a Paradigm ShiftNeo-Kraepelinian (strict categorical) to
Spectrum Gene-Environmental Interaction-dimensional
New Developments
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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
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DSM-5: Classification, Criteria, and Use
Section II: Chapter Structure
A. Neurodevelopmental DisordersB. Schizophrenia Spectrum and Other Psychotic
DisordersC. Bipolar and Related DisordersD. Depressive DisordersE. Anxiety DisordersF. Obsessive-Compulsive and Related DisordersG. Trauma- and Stressor-Related DisordersH. Dissociative Disorders
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Section II: Chapter Structure
J. Somatic Symptom and Related DisordersK. Feeding and Eating DisordersL. Elimination DisordersM. Sleep-Wake DisordersN. Sexual DysfunctionsP. Gender Dysphoria
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Section II: Chapter Structure
Q. Disruptive, Impulse-Control, and Conduct Disorders R. Substance-Related and Addictive DisordersS. Neurocognitive DisordersT. Personality DisordersU. Paraphilic DisordersV. Other DisordersMedication-Induced Movement Disorders and Other
Adverse Effects of MedicationOther Conditions That May Be a Focus of Clinical
Attention
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DSM-5: Classification, Criteria, and Use
How many disorders are in Section II?
ChangesinSpecificDSMDisorderNumbers;CombinationofNew,Eliminated,andCombined
Disorders(netdifference=15)
DSMIV DSM5
SpecificMentalDisorders* 172 157
*NOS (DSM-IV) and Other Specified/Unspecified (DSM-5) conditions are counted separately.
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NewandEliminatedDisordersinDSM5(netdifference=+13)
NewDisorders1. Social(Pragmatic)CommunicationDisorder2. DisruptiveMoodDysregulationDisorder3. PremenstrualDysphoricDisorder(DSMIVappendix)4. HoardingDisorder5. Excoriation(SkinPicking)Disorder6. DisinhibitedSocialEngagementDisorder(splitfromReactiveAttachmentDisorder)7. BingeEatingDisorder(DSMIVappendix)8. CentralSleepApnea(splitfromBreathingRelatedSleepDisorder)9. SleepRelatedHypoventilation(splitfromBreathingRelatedSleepDisorder)10. RapidEyeMovementSleepBehaviorDisorder(ParasomniaNOS)11. RestlessLegsSyndrome(DyssomniaNOS)12. CaffeineWithdrawal(DSMIVAppendix)13. CannabisWithdrawal14. MajorNeurocognitiveDisorderwithLewyBodyDisease(DementiaDuetoOther
MedicalConditions)15. MildNeurocognitiveDisorder(DSMIVAppendix)EliminatedDisorders1. SexualAversionDisorder2. PolysubstanceRelatedDisorder
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DSM-5: Classification, Criteria, and Use
CombinedSpecificDisordersinDSM5(netdifference=28)
1. LanguageDisorder(ExpressiveLanguageDisorder&MixedReceptiveExpressiveLanguageDisorder)
2. AutismSpectrumDisorder(AutisticDisorder,AspergersDisorder,ChildhoodDisintegrativeDisorder,&RettsdisorderPDDNOSisintheNOScount)
3. SpecificLearningDisorder(ReadingDisorder,MathDisorder,&DisorderofWrittenExpression)
4. DelusionalDisorder(SharedPsychoticDisorder&DelusionalDisorder)
5. PanicDisorder(PanicDisorderWithoutAgoraphobia&PanicDisorderWithAgoraphobia)
6. DissociativeAmnesia(DissociativeFugue&DissociativeAmnesia)
7. SomaticSymptomDisorder(SomatizationDisorder,UndifferentiatedSomatoformDisorder,&PainDisorder)
8. InsomniaDisorder(PrimaryInsomnia&InsomniaRelatedtoAnotherMentalDisorder)
9. HypersomnolenceDisorder(PrimaryHypersomnia&HypersomniaRelatedtoAnotherMentalDisorder)
10. NonRapidEyeMovementSleepArousalDisorders(SleepwalkingDisorder&SleepTerrorDisorder)
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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))
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ChangesfromNOStoOtherSpecified/Unspecified
(netdifference=+24)
OtherSpecifiedandUnspecifiedDisordersinDSM5replacedtheNotOtherwiseSpecified(NOS)conditionsinDSMIVtomaintaingreaterconcordancewiththeofficialInternationalClassificationofDiseases(ICD)codingsystem.Thisstatisticalaccountingchangedoesnotsignifyanynewspecificmentaldisorders.
DSMIV DSM5
NOS(DSMIV) and OtherSpecified/Unspecified(DSM5)
41 65
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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
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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)
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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)
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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
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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
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.
How are DSM-5 and ICD Related?
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DSM-5: Classification, Criteria, and Use
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.
How are DSM-5 and ICD Related?
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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.
How DID DSM-IV Handle ICD Coding?
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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.
DSM-5 and ICD Codes
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DSM-5: Classification, Criteria, and Use
Codes accompany each criteria set, but some codes are used for multiple disorders.
For example, hoarding disorder and obsessive-compulsive disorder share the same codes (ICD-9-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.
DSM-5 and ICD Codes
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For some disorders, unique codes are given for subtypes, specifiers, and severity (e.g., major depressive disorder).
For neurocognitive and substance/medication-induced disorders, coding depends on further specification.
DSM-5 and ICD Codes
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For neurocognitive and substance/medication-induced 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.
DSM-5 and ICD Codes
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DSM-5: Classification, Criteria, and Use
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-9-CM 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).
Inconsistencies in DSM and ICD Code Names
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APA has been working with CDC/NCHS and CMS to include new DSM-5 terms in the ICD-10-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.
Inconsistencies in DSM and ICD Code Names
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New DSM-5 Diagnoses Code IssuesDSM-5 Disorder ICD-9-CM
CodeICD-9-CM Title ICD-10-CM
CodeICD-10-CM Title
Social (Pragmatic) Communication Disorder
315.39 Other developmental speech or language disorder
F80.89 Other developmental disorders of speech and language
Disruptive Mood Dysregulation Disorder
296.99 Other Specified Episodic Mood Disorder
F34.8 Other Persistent Mood [Affective] Disorder
Premenstrual Dysphoric Disorder (from DSM-IV appendix)
625.4 Premenstrual tension syndromes
N94.3 Premenstrual tension syndrome
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DSM-5: Classification, Criteria, and Use
New DSM-5 Diagnoses Code IssuesDSM-5 Disorder ICD-9-CM
CodeICD-9-CM Title ICD-10-CM
CodeICD-10-CM Title
Hoarding Disorder
300.3 Obsessive Compulsive Disorders
F42 Obsessive Compulsive Disorder
Excoriation (Skin Picking) Disorder
698.4 dermatitis factitia [artefacta]
L98.1 factitial dermatitis
Binge Eating Disorder (from DSM-IV Appendix)
307.51 bulimia nervosa F50.2 bulimia nervosa
Substance Use Disorders
Coding will be applied based on severity: ICD codes associated 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
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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.
Changes to the Multiaxial System
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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-practice-guidelines).
Changes to the Multiaxial System
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DSM-5: Classification, Criteria, and Use
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.
Changes to the Multiaxial System
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For some diagnoses, functioning can also be assessed using the diagnostic-specific severity measures, which are available online. (www.psychiatry.org/dsm5)
Changes to the Multiaxial System
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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 v-code or z-code reason for visit should be listed first.
How Should DSM-5 Diagnoses Be Recorded?
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DSM-5: Classification, Criteria, and Use
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.
How Should DSM-5 Diagnoses Be Recorded?
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Example I. 243 Congenital hypothyroidism296.22 Major depressive disorder, single episode, moderateV62.4 Acculturation difficulty V65.40 Other counseling or consultation (nicotine use)
Example II.307.1 Anorexia nervosa, restricting subtype 300.02 Generalized anxiety disorder V62.3 Academic or educational problem
Examples of How Diagnoses and Conditions May Be Recorded
Example III. 332.0 Parkinsons disease 294.11 Major neurocognitive disorder probably due to Parkinsons disease, with behavioral disturbance V60.3 Problem related to living alone
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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.
Important Insurance Considerations
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DSM-5: Classification, Criteria, and Use
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 DSM-5 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.
Important Insurance Considerations
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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/DSM5CodingSupplement
DSM-5 Coding Updates
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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/SMA14-4804/SMA14-4804.pdf
For more information about DSM-5 implementation, a detailed Frequently Asked Questions document can be found at www.dsm5.org
Further Questions?
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DSM-5: Classification, Criteria, and Use