Are You SURE You Have the Right Diagnosis Code?
By Barbara Griswold, LMFT
January 17, 2019
Q: I was surprised to hear you say at a recent workshop that some diagnosis codes in the DSM-5 are already out of date and no longer eligible for reimbursement. How can I know if a code is still good?
Many therapists aren’t aware that diagnosis codes go through changes routinely, which can lead to claim denials for you or your clients. This means even if you shelled out all that money back in 2013 for the DSM-5, some key ICD-10 codes (the diagnosis codes from the DSM-5) aren’t accurate anymore. Even if are not a network provider for any insurance plans, you still need to keep up to date so you are using accurate diagnosis codes in client charts and on client invoices (I don’t like the word “superbill”– as my dear friend Casey Truffo once said, who wants to get a “super” bill?).
Remember that for each listed diagnosis the DSM-5 gives both the old ICD-9 codes which were in effect until 2013 (ex. 309.28) as well as the new ICD-10 codes (ex. F43.23) implemented in 2015. But updates of some common diagnosis codes have happened each year since, eliminating many codes.
But you can rest easy, thanks to a free resource you can use to quickly check that a diagnosis is still in use: www.icd10data.com. At this website, you can type in codes: The code will have a tiny green triangle to the left of the code name if still billable, or a red triangle if no longer eligible. You can even use the search bar to type in code names to look for the coding choices, or look up by the old ICD-9 code number to find out the new ICD-10 code.
Let’s say you think the OCD diagnosis code is F42. Go to www.icd10data.com, and in the white search bar in the blue header, type “F42” and hit “Search.” On the results page, you will see a red triangle to the left of “ICD-10-CM Diagnosis Code F42,” signifying it is not a billable code. Click on the link to the right of the triangle which says “ICD-10-CM Diagnosis Code F42.” If you read carefully on the next page, it says “F42 should not be used for reimbursement purposes as there are multiple codes below it that contain a greater level of detail.” This means that F42 has been split into multiple diagnoses that each need another digit after the decimal point to specify which you are referring to. Click on the blue words “greater level of detail,” and scroll way down the next page and you’ll see F42 is now divided into 5 possible billable disorders:
- F42.2 Mixed obsessional thoughts and acts
- F42.3 Hoarding disorder
- F42.4 Excoriation (skin-picking) disorder
- F42.8 Other obsessive-compulsive disorder
- F42.9 Obsessive-compulsive disorder, unspecified
So, if I choose a billable code, does that mean the insurance plan will cover it? Nope. Coverage and reimbursement rates vary with the plan. For example, unspecified diagnoses like the last one here should be avoided whenever possible, since some insurance plans may not reimburse them. But at least your claims will not be denied because you’ve used the wrong code!
Can this website take the place of my DSM-5? No, you still need your trusty DSM for the diagnosis criteria and differential diagnoses information. But this website is a great adjunct. And it’s free — who doesn’t like that?
Where would I go to find a list of all changes since the DSM came out, or to learn about future changes? You can look back to find out about the last several years of changes to the DSM-5 mental health diagnoses, and watch for future updates, by visiting the American Psychiatry Association website. Also, sign up for my e-news for updates on codes (I always report on them as they happen), and check out the Articles page of my website for past reports on changes that have already occurred.