DSM-5 Transition and State Benefit Plans (Target Pop) Implementation

 

  

Transition to DSM-5  

As of Aug. 1, 2014, all requests for services should be linked to an appropriate DSM-5 diagnosis. While some disorders may have the same name as currently exists in the DSM-IV, the specific clinical criteria may have changed. In a number of cases, DSM-IV diagnoses no longer exist in the DSM-5, and new diagnoses will need to be established. For individuals who are new to services, Smoky will require a DSM-5 diagnosis upon admission with supporting source documentation, effective Aug. 1, 2014.

For individuals who request reauthorization of service on or after Aug. 1, 2014, where there is an equivalent diagnosis to which the DSM-IV can be clearly cross-walked to a DSM-5 diagnosis, the DSM-5 diagnosis needs to be used. An example is a well-established DSM-IV diagnosis of autistic disorder, Asperger's disorder or Pervasive Developmental Disorder not otherwise specified should be given the diagnosis of Autism Spectrum Disorder (DSM-5 manual, page 51). In these cross-walked diagnoses, providers should include a clinical note to indicate this change. For diagnoses that do not clearly crosswalk, we recognize that final implementation and required documentations, assessments, and/or evaluations will require a period of time. Therefore, providers will have until Jan. 1, 2015, to fully establish a DSM-5 diagnosis, which should be done by an appropriately licensed individual. An example would be a DSM-IV diagnosis of Reactive Attachment Disorder, which does not have a corresponding DSM-5 diagnosis and would therefore require a new evaluation by a licensed professional for appropriate diagnostic classification.

For consumers who are still within the unmanaged portion of services, the transition to DSM-5 should be made by the time an authorization is requested but no later than July 1, 2015.

ICD-9 Coding
AlphaCM will be adding an indicator field to the ICD-9 code table to be marked to indicate if it is a DSM-5 code. N.C. DMA will also be producing a list of IDD codes that are not currently a part of the DSM-5 but that will be available in the state system. Those will also be marked on the ICD-9 table. ICD-9 codes will remain the code set in use for filing claims and billing and are expected to be until such time as ICD-10 is adopted. Current ICD-9 codes will remain available for claims through June 30, 2015. The AlphaMCS system utilizes only ICD-9 codes for claims. Since the coding system will remain unchanged from DSM-IV-TR to DSM-5, the DSM-IVR codes will remain available through fiscal year 2015, allowing providers to bill DSM-IV-TR codes with dates of service prior to Aug. 1, 2014. An example is someone who has previously had a diagnosis of "catatonic schizophrenia" who will get a new authorization of simply "schizophrenia" after Aug. 1; however, if the provider continues to bill the valid ICD-9 code that continues to exist for "catatonic schizophrenia," AlphaCM will flag that to let the provider know the billing code does not match the diagnosis, but claims will continue to be honored through fiscal year 2015.

The Benefit Plan
Effective Aug. 1, 2014, the DMHDDSAS Benefit Plans, formerly known as Target Population Categories (target pops), are being revised. Several benefit plans (categories) are expiring and will end effective July 31, 2014. The number of benefit plans is reduced from 35 to 10. The following benefit plans remain in effect Aug. 1, 2014: AMI, CMSED, ADSN, CDSN, ASTER, CSSAD, ASWOM, ASCDR and AMVET. GAP (Generic Assessment Payment) has been added and collapses the current six age/disability-specific assessment outreach ones. 

 
The target pops are being mapped to specific diagnosis found in DSM-5. Please see communication bulletin #142 as referenced above for information on benefit plans, diagnostic array and service array.

  

Smoky's implementation of the State Benefit Plan changes will include a crossover of consumers from these retiring target pops into the 10 benefit plans that will remain in place as of Aug. 1, 2014. This one-time transition will be handled on an automated systems basis and will be completed on or before Aug. 1, 2014. 

• Providers are not required to submit a new eligibility update for most consumers. 
• Providers must verify that the transition has been processed to the appropriate benefit plan and to enter any updates that may be required either to correct an incorrect assignment or to update the consumer target population if there is a change.
• Providers must identify for all new consumers being enrolled into the State Benefit Plan with Smoky the correct target population based on the information in Communication Bulletin # 142.
• Providers can expect any SARs that continue to reference an expired State Benefit Plan on or after Aug. 1, 2014, to be denied and returned for correction.

Inclusion in DMHDDSAS Benefit Plans after July 31, 2014, shall be based on the covered DSM-5 diagnoses and eligibility criteria listed in the attached documents. ICD-9 diagnosis codes covered in fiscal year 2014 will continue to be allowed for claims adjudication in NCTracks through the end of fiscal year 2015 for the benefit plans that are not expiring. Please see Communication Bulletin #142 for information on benefit plans, diagnostic array and service array.

 

The Smoky AlphaMCS system recently added the target population field into the consumer file that is available to providers in the download queue. This file contains consumers who have been related to the provider by claims, SARs, authorizations, referrals, enrollment, client updates or clinical home assignment over the previous 12 months. This file is updated on a weekly basis on Sundays, and the latest version is available in the provider download queue.