When it comes to insurance billing, accurate diagnosis and specification of a disorder are vital to proving medical necessity. To support this effort, and to apply recent research, update necessary definitions, specifiers, and diagnoses, the DSM-5 has announced a revised version.
DSM-5 was put into place in 2013, and a revision is long overdue. “...Nine years have elapsed since the publication of DSM-5 in 2013, longer than historical revisions to DSM after five to seven years.” Significant changes have been included in the update, which could impact insurance reimbursement such as the addition of grief disorder, symptom codes for suicidal behavior, and non-suicidal self-injury.
The addition of Prolonged Grief Disorder stands out as one of the most prominent additions. “First said, the addition is the result of years of research and clinical experience indicating that some people experience a pervasive inability to move past grief over the loss of a loved one and that these symptoms are severe enough to affect day-to-day functioning. It is estimated that following the nonviolent loss of a loved one, 1 in 10 bereaved adults is at risk for developing prolonged grief disorder.”
DSM-5-TR update also includes codes that will allow providers to indicate the presence or history of suicidal behavior and non-suicidal self-injury. “The suicidal behavior symptom code can be used for individuals who have engaged in potentially self-injurious behavior with at least some intent to die as a result of the act.”
In addition to these updates, definitions changes for several disorders were made. Changes include severity specifiers for a manic episode, the mood-congruent/mood incongruent specifier for bipolar disorder, the mixed features specifier for major depressive disorder, the acute/persistent specifier for adjustment disorder, narcolepsy specifiers, and the post-transition specifier for gender dysphoria.
Lastly, two disorders have been renamed to adopt current usage: Intellectual disability is now referred to as "intellectual developmental disorder," and conversion disorder is now "functional neurological symptom disorder."
It will take some time to determine how changes to the DSM will impact insurance billing. How will ICD codes adapt? It seems logical that these revisions will lead to more specific diagnoses and, thus, more accurate determinations by the insurance provider.
Contributing author: Alexis Swanson