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DSM-IV-TR Coding Alert: New Diagnostic Codes for Sleep Disorders Effective October 1, 2005

A number of new code numbers for sleep disorders were added to the ICD-9-CM at the request of the American Academy of Sleep Medicine, which concurrence of the American Psychiatric Association, making several of the current DSM-IV-TR code numbers obsolete. Please refer to the DSM-IV-TR Coding Alert page for more details.


Diagnostic Coding and DSM-IV-TR


In many ways the diagnostic codes constitute the most “clinically relevant” part of DSM-IV-TR.  For many clinicians, the three, four, and five digit codes associated with each DSM-IV-TR disorder are the only components of the diagnostic system used on a daily basis.   These codes have direct relevance to the practical bottom line of clinical practice:  no diagnostic code, no payment.  

Many people wonder why the diagnostic codes seem so illogically assigned.  Why don't they start at 1 and go to 100, for instance?   However much we would have liked to make the numbering system simple and straightforward, the APA does not control the DSM-IV diagnostic codes.   All of the codes are taken from the International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9-CM), the official coding system used by the United States Government and all private insurers to classify medical conditions and causes of injury or death.  (Click here for more information about ICD-9-CM  and to download a copy).  The diagnostic codes for mental disorders, which have been designated to range from 290-319 are but a small part of this much larger system (which goes from 1-999). When the ICD-9 system was originally devised in the early 1970's, the codes were assigned according to a particular logical scheme: three digit codes were the highest order categories (e.g., Senile and presenile organic conditions, Alcoholic psychoses, Schizophrenic disorders, Affective psychoses, Paranoid states, etc.), most of which were divided further into ten four digit categories (eg. 290.0 Senile dementia uncomplicated, 290.1 Presenile dementia, ... 290.9 Unspecified senile psychotic condition) and most of these divided further into five digit categories.         

DSM-IV-TR diagnostic codes have been selected by carefully perusing the ICD-9-CM system and picking the ICD-9-CM code that best corresponds to each DSM-IV-TR category.   Since all DSM-IV-TR diagnostic codes represent valid ICD-9-CM codes, clinicians can use the DSM-IV-TR codes in any situation in which a valid ICD-9-CM code is required (e.g., Medicare and other insurance forms).   Thus, the HIPAA requirement for clinicians and hospitals to use ICD-9-CM codes for diagnostic purposes is met by using the codes in the DSM-IV-TR.   The continued use of the DSM-IV-TR diagnostic criteria for psychiatric diagnosis has been officially sanctioned by the Center for Medicare Services, according to two statements in the Frequently Asked Questions section of the CMS web site.   In response to the question “Can clinicians continue current practice and use the DSM-IV diagnostic criteria?,” the site states “clinicians may continue to base their diagnostic decisions on the DSM-IV criteria, and, if so, to crosswalk those decisions to the appropriate ICD-9-CM codes. In addition, it is still perfectly permissible for providers and others to use the DSM-IV codes, descriptors and diagnostic criteria for other purposes, including medical records, quality assessment, medical review, consultation and patient communications.”  (Click here for the complete entry on the CMS web site)  Furthermore, in response to the question “Can mental health practitioners, agencies, institutions and others still use DSM-IV diagnostic criteria, even though DSM-IV has not been adopted as a HIPAA code set?,” the site notes that “the basic purpose for adopting code sets under HIPAA is to standardize the ‘data elements' used in the electronic processing of certain administrative and financial health care transactions. While the patient's diagnosis is a data element used in such transactions, the criteria considered by the clinician in reaching a diagnosis are not. Practitioners are free to use the DSM-IV diagnostic criteria—or any other diagnostic guidelines—without any HIPAA-related concerns.” (Click here for the complete entry on the CMS web site)

Note that in some cases, several DSM-IV-TR disorders share the same ICD-9-CM code.   This is not a mistake—DSM-IV-TR in some cases includes greater diagnostic specificity than ICD-9-CM.  For example, ICD-9-CM only recognizes alcohol-induced dementia, amnestic disorder, and psychotic disorders and does not include specific categories for alcohol-induced mood, anxiety, and sleep disorders.   Thus, all of these DSM-IV-TR categories share the same ICD-9-CM, 291.89, which corresponds to the ICD-9-CM category “Other alcohol-induced disorder.”

There are two caveats to the coding compatibility between DSM-IV-TR and ICD-9-CM:

1) Updates are made to the entire ICD-9-CM diagnostic coding system by the US Government on a yearly basis, with changes becoming mandatory each January 1st. When DSM-IV-TR was initially printed in May 2000, all diagnostic codes were updated to insure that they were up-to-date (to reflect coding changes effective the following October 2000). Since May 2000, there have been four cycles of coding changes (October 2001, October 2002, October 2003 and October 2004). The following coding changes reflect all of the coding changes (through October 2004) that affect DSM-IV-TR. (Note: DSM-IV-TR is periodically reprinted as supplies at the publisher run low. At the time of each printing, diagnostic codes are updated to reflect these annual updates). See below for a list of all coding changes made in DSM-IV-TR since its initial printing in May 2000.

2) Although all codes in DSM-IV-TR are valid ICD-9-CM codes, technical differences in ICD-9-CM coding rules can result in slightly different results when looking up codes in DSM-IV-TR vs. ICD-9-CM, mainly in the order that the codes are listed.   This is of interest primarily to coders.  Click here for a complete (and mostly arcane) explanation of all such differences.

Coding Changes in DSM-IV-TR since May 2000 Publication

1) There have been two changes in diagnostic coding that affect the DSM-IV-TR codes themselves. The first, effective October 1, 2004, is that the code for Narcolepsy has been changed to 347.00 from 347. The second, effective October 1, 2003, is that code for Age-Related Cognitive Decline has been changed to 780.93 from 780.9.

2) Two changes in diagnostic codes reflect changes in general medical condition codes that impact on DSM-IV-TR coding. 

Dementia Due to Parkinson's Disease:  on Axis III, one should now code:  331.82 Dementia with Lewy Bodies

Dementia Due to Pick's Disease:  on Axis III, one should now code 331.11 Pick's disease.

3) Appendix G in DSM-IV-TR includes a list of “ICD-9-CM Codes for Selected General Medical Conditions and Medication-Induced Disorders.”   Changes in ICD-9-CM codes for general medical conditions have necessitated the following updates:

Page 868: Encephalopathy, unspecified.  Should be 348.30* (instead of 348.3*)

Page 869: Myasthenia gravis.  Should be 358.00* (instead of 358.0)

Page 869: Pick's disease.  Should be 331.11 (instead of 331.1)

Page 872: Dwarfism, pituitary. Should be 253.3 (instead of 252.2)

Page 872: Hyperaldosteronism.  Should be 255.10* (instead of 255.1)

Page 874: Diverticulitis of colon, unspecified should be 562.11 (instead of 562.10)

Page 874: Diverticulitis of colon, with hemorrhage should be 562.13 (instead of 562.12)

Page 874: Diverticulosis of colon, unspecified, should be 562.10 (instead of 562.11)

Page 874: Diverticulosis of colon, with hemorrhage should be 562.12 (instead of 562.13)

Page 875: Hypertrophy, prostatic, benign (BPH).  Should be 600.00* (instead of 600.0)

Page 875: Thalassemia.  Should be 282.49* (instead of 282.4)