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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


Webinar Housekeeping

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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


Darrel A. Regier, M.D., Ph.D.Vice-Chair, DSM-5 Task Force

Senior Scientific Consultant & Former Research Director (2000-2014),

American Psychiatric Association



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

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


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



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


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)


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



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


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



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



J. Somatic Symptom and Related DisordersK. Feeding and Eating DisordersL. Elimination DisordersM. Sleep-Wake DisordersN. Sexual DysfunctionsP. Gender Dysphoria



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



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.


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



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)


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))


ChangesfromNOStoOtherSpecified/Unspecified

(netdifference=+24)

OtherSpecifiedandUnspecifiedDisordersinDSM5replacedtheNotOtherwiseSpecified(NOS)conditionsinDSMIVtomaintaingreaterconcordancewiththeofficialInternationalClassificationofDiseases(ICD)codingsystem.Thisstatisticalaccountingchangedoesnotsignifyanynewspecificmentaldisorders.

DSMIV DSM5

NOS(DSMIV) and OtherSpecified/Unspecified(DSM5)

41 65



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


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)



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)


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



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?



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?


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?


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



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


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


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



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


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


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



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


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


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).




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.



For some diagnoses, functioning can also be assessed using the diagnostic-specific severity measures, which are available online. (www.psychiatry.org/dsm5)



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?



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?


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


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



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


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


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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