BREAKING: Virginia Medicaid abandons DSM-5

This week, Virginia’s Medicaid program reminded providers that they must make the switch from ICD-9 to ICD-10 diagnostic coding on October 1, 2015, to comply with federal regulations. However, at the same time, officials announced they are essentially abandoning the longstanding DSM diagnostic code sets.

The decision is groundbreaking as no other state has made such a move.

Making the choice

The announcement came from Magellan, which has an exclusive contract with the Virginia Department of Medical Assistance Services (DMAS) as the state’s behavioral health administrator. Magellan manages everything from network development to claims processing.

Dropping DSM is significant because up until now, behavioral health providers have generally used both code sets for diagnosis—ICD and DSM—often without realizing it because the sets have been aligned. According to experts, the latest editions of each set (ICD version 10 and DSM version 5) are not entirely aligned, however. There is a one-to-one correlation of codes in some but not all clinical situations.

With federal regulations from the Centers for Medicare and Medicaid Services (CMS) mandating all medical health providers move to ICD-10 in the fall, the momentum seems to favor adopting ICD as the more universal code set for behavioral health providers, given the choice. Also, ICD is the HIPAA-compliant code set. What is difficult for providers is that historically most have only been trained to use the DSM.

“There is a question as to whether or not there is a future for DSM,” says Lisette Wright, a behavioral health and informatics consultant. “People ask me why they need the DSM if they can use ICD, and I don’t have an answer for that.”

Cindi B. Jones, director of DMAS, tells Behavioral Healthcare the department will be implementing the federal ICD-10 mandate for all Medicaid providers. 

"Magellan, as a contractor for DMAS, must also implement the same standard," Jones says. "The purpose of this notice is to give providers clarification regarding the billing and documentation changes that will occur as a result of this requirement. Providers must prepare their system programs and operational policy and procedures to meet the October 1, 2015, transition date."

Behavioral health’s two code sets

In today’s announcement Magellan says: “Magellan understands that the DSM will continue to be used for diagnostic and educational resource purposes given it being the longstanding standard for diagnostic evaluations and coding, set forth by the American Psychiatric Association (APA). As such, clinicians may continue to utilize DSM-5 diagnosis codes in the non-electronic medical record or in the narrative portion of the electronic medical record.” 

Wright says Magellan’s move is forward-thinking.

“They have struck a nice balance between being compliant with CMS and HIPAA directives, yet they acknowledge the industry’s historical reliance on the DSM series,” Wright tells Behavioral Healthcare. “Unfortunately, we are the only set of healthcare providers in the United States who must use two different manuals to transition to ICD-10.”

Diagnosis differential

Critics of DSM-5, which is produced by APA and sold as a guidebook and electronic tool, have said this latest version released in May 2013 appears highly political and have balked at some of its guidelines. For example, one change places several disorders, such as Asperger’s, on the autism spectrum, which drew ire from advocacy groups.

In an exclusive interview, APA officials tell Behavioral Healthcare that DSM has never been a unique code set, and that it has always corresponded to ICD, therefore, providers don’t need to panic. They can keep using DSM as they always have. In fact, according to APA, behavioral health providers are in better shape than medical providers because APA has already done the transition work for them, providing a diagnosis differential, which they believe goes beyond what ICD provides.

ICD is driven by the World Health Organization and is available at no charge.

Although ICD is used by medical providers worldwide, mental health and substance-abuse treatment providers are more often trained on DSM codes. Passions are running high on both sides, Wright says.

She also says providers must start to learn the ICD codes, and educational institutions must start to teach them, which isn’t happening now.

While the DSM-5 does attempt to list the corresponding ICD-10CM code, it is not sufficient, Wright says. For example, many of the DSM-5 cross-mapped codes lead to unspecified diagnoses in the ICD-10. She believes the possible increase in “not otherwise specified (NOS)” may put providers at risk.

The whole point of ICD-10 adoption by CMS has been to drive greater specificity in healthcare documentation.

“While I recognize that ICD/DSM harmonization is a goal of several entities, I do wonder if this can ever really be accomplished, when it will be accomplished, and who will make those decisions,” Wright says. “Hopefully those without a conflict of interest will drive that boat.”

Going forward, Magellan says it will be the clinician's responsibility for ensuring the identified DSM diagnosis “properly and accurately aligns with the ICD-10CM diagnosis for billing and coding purposes.”

This article was updated at 2:45 pm to include the comments from Jones.