This is a presentation on how DSM5, ICD-9, and ICD-10 work together to create diagnosis acceptable for use in the Avatar system. In addition this presentation also helps us better understand how to use the manuals mentioned above. I placed all information on the slides, so feel free to move the information to notes or create bullets in relation to the topic. Good luck. Ken Letizia.

1. DSM-5 Why the change?
The DSM 5 is now in line with the codes used universally all over the world.
These are the codes you will find in the ICD-9-CM and ICD-10-CM.
The old system of diagnostics involved a V tier multiaxial system which the
DSM-5 no longer recognizes.
There is a clear definition of spectral disorders and specifiers to support the
diagnosis.
Macro understanding of the ct. through ct. specific identifiers like; age,
gender, spiritual and cultural influence.
A reorganization of the DSM 5 creates whole sections devoted to the better
understanding of use, coding, measures, and models. In addition, close
attention was given to providing several clearly defined Appendix to aid the
clinician in diagnosis.
In the new DSM 5, the NOS diagnosis has been removed, due to complacent
overuse by clinicians.

2. 10-9-5-IV LIFTOFF!!!
I. DSM 5 is compatible with both ICD-9 and ICD-10.
Additionally: The DSM 5 does contain both sets of codes.
I. DSM IV is compatible with ONLY ICD-9-CM codes.
II. DSM IV IS NOT Compatible with ICD-10-CM codes.
III. All mental health clinicians should posses one of these
two diagnostic tools ICD-10-CM or DSM 5.
IV. If you do not have a DSM 5 you can go to:
http://www.icd10data.com/open this link and place it in your
action bar on your Google Chrome or Firefox. Trust me you will use it often
and it eliminates the need to page through the DSM 5 or ICD-9 or ICD-10 for
the more common diagnoses.
V. The DSM 5 must be on-sight at all times, for compliance with new
County based system now in place.

3. Four Sections of the DSM-5
I. Section I contains: DSM 5 Basics, the how to of
the DSM 5
 Introduction to the DSM 5
 Proper use of the DSM 5
 Coding using the DSM 5, ICD-9, or ICD-10
II. Section II: Diagnostic Criteria and Codes
 Present the categorical diagnoses according to a revised 20 chapter organization that eliminates
the multiaxial system
III. Section III: Emerging Measures and Models
 Assessment Measures
 Cultural Formulation
 Alternative DSM-5 Model for Personality Disorders
 Conditions for Further Study
• Appendix
 Highlights of Changes From DSM-IV to DSM-5 – Glossary of Technical Terms
 Glossary of Cultural Concepts of Distress
 DSM-5 Diagnoses and Codes (ICD-9-CM and ICD-10-CM)

4. Using the DSM 5
DSM 5 uses a single axis system that combines the former Axis I-III codes
– Mental Disorders/SUD
– Medical Disorders
– Other Conditions that May be the Focus of Clinical Attention (e.g., V- Codes)
Is there a way of noting contextual or situational factors like we did with
Axis IV?
use the expanded ICD-10 Z-codes. Z codes are only for the therapists better
understanding of the ct. needs do not use in Dx.
– World Health Organization Disability Assessment Schedule 2.0
 (WHODAS 2.0)
 Provided in Section III (pp. 745-748) as the best current alternative for measuring disability:
various disorder-specific severity scales (6 domains)
 Download at: http://www.who.int/classifications/icf/whodasii/en/
– WHODAS is NOT required for a diagnosis

5. Steps in Writing a Diagnosis
I. Identification of the disorder:
Through cooperation with the ct. clearly identify issues leading to Tx. and issues
currently faced by the ct.
II. Write out the name of the disorder:
Ex.: Posttraumatic Stress Disorder
III. Now add any subtype or specifiers that fit the presentation:
Ex.: Posttraumatic Stress Disorder, with dissociative symptoms, with delayed
expression, childhood trauma mental and physical abuse, severe
• Add the code number (located either at the top of the criteria set or within the
subtypes or specifiers):
Two codes one in bold-ICD-9: one in parentheses (ICD-10).
Ex: 309.81 (F43.10)
 As of October 1, 2015 use the ICD-10 code that is in parentheses:
An example might read like this; depending on the clinician:
Ex: (F43.10) Posttraumatic Stress Disorder, with dissociative symptoms, with
delayed expression, due to childhood abuse mental and physical, severe.
III. Order of multiple diagnoses: One ct. may have many Dx. at one time: Next slide
will give an example.

6. The Narrative
Narrative summary: This is a written objective
statement of the information collected at intake and how the
elements contained in the information contributed to the
client's presenting problem.
Writing the narrative: The narrative is written by the
Therapist or Intake Personnel. This narrative is meant to sum
up the issues and contributing factors to the client’s condition
leading to Tx. and how the ct. is functioning today.

7. Progress Narrative
Progress Summary Narrative: A clearly defined synopsis of the ct’s.
progress while in treatment.
I. How has the ct. has grown: Where has the ct. gained better
understanding or shown growth?
II.What area’s of growth are exhibited: How does the ct. relate
the newly reframed information? What behaviors in the ct. are
notably observable by the therapist/counselor?
III.What is the anticipated direction of Tx: Does the therapist
believe the ct. would benefit from further exploration of the current
issue; or has the ct. shown significant progress concerning the
current issue to begin work in other areas of the ct’s. life?
IV.Overall response to therapeutic intervention: Clinician’s own
observation of the ct’s. growth and progress. This is an unbiased
objective, not subjective point of view that either supports ct.
growth, or states ct. current condition.
V.What is the Narrative: In truth the narrative is a clear and
concise objective statement that identifies the ct’s. Growth,
Understanding, Therapeutic need/diagnosis, and Progress in
Tx.

8. Ph.D. Frothwick Von Einstein
 Frothy, as he is known by friends and family, is 42 year old Caucasian male, father of 3 grown
children and a is married. referred by the Solano County court system. Frothy, has recently
been convicted of a DUI. He state’s he was at a ball game, had couple of beers and felt fine to
drive home. Frothy, is experiencing depressive symptoms due to his own shame and
embarrassment. Frothy, is a noted Professor of Archeology on campus and this could reflect
poorly on his character and reputation. He’s worried about the financial expense and loss of
his license for a year. He’s had a hard time sleeping because of the worry and depressed
reaction he’s experienced since the DUI. Frothy has had several anxiety attacks and, “they
just come out of the blue.”
 Upon further investigation, you find that Frothy, drinks “several” beers most nights of the
week. He states, “I drinks 6-8 beers a day, sometimes more, sometimes less.” He has
attempted to reduce his intake, but has been unsuccessful in his own efforts. Over time
Frothy, has found it necessary to consume almost twice the amount of beer he used to in
order to get the same buzz –on.
 In addition Frothy, smokes marijuana with his students, and has began dabbling with hookah
pipes. He smokes marijuana 3-4 times a week and when he tries to cut back, he finds himself
feeling strong urges to get high.
 Frothy, also smokes a pipe and cigars, and cannot go one day without some sort of smoking.
How would you Dx. Ph.D. Frothwick Von Einstein:
 Dx. will vary from clinician to clinician, so do not worry about wrong answers. Both SUD
and Mental Health will see this from their own perspectives, and that is fine.

9. • Provide copy of this slide for Dx.
• Remember Mental Health and SUD will see
this case from two different perspectives. So
there is not one right or wrong answer to this
example.
• 309.0 Adjustment disorder with mixed
anxiety and depressed mood
• 305.00 Alcohol use disorder, mild
• 305.20 Cannabis use disorder, mild
• 305.1 Tobacco use disorder, mild

10. ICD 10 Behavioral Science
Current ICD 10 codes, must be used in all Dx.
situations.
Two exceptions to this rule…
One: DUI does not convert to ICD 10 and therefore
the old codes are still available in the system for the
DUI program. Mental Health and SUD cannot use
these codes!
Two: When no Z code can best describe the current
ct. level of discomfort, the V codes from ICD 9 are still
valid. Make every attempt to avoid V and Z codes, as
this will impact billing. The full impact of the ICD
changes have not been felt in all fields, and the less
confusing we make it for the insurance co., the better
it is for all of us.

11. 7 digit coding
ICD 10 uses up to a 7 digit coding format with the letter “x” as a place
holder in the Dx. Digits greater than 5 are essentially for the medical field
and will not be used by the Behavioral Sciences.
In both Mental Health and SUD, all codes will begin with the first digit “F”
which is used to indicate Mental Health disorder or SUD, to be followed by
the code numbers that specify the issue itself.
We in the mental health/SUD field will be using codes no greater that 5
digits for billing purposes, and 6 digits for descriptive criteria a ct. may be
experiencing.
EXAMPLE: Ct. suffers from F43.10 PTSD, recurrent episode, physical
abuse, childhood. Abuse related to Z62.810 past hx. of sexual abuse in
childhood by so-and-so. In addition ct. is experiencing F33.2 Major
Depressive Disorder, recurrent episode severe, without psychotic
features. Ct. experiences F41.1 GAD as it relates to the above Dx. and the
ct’s. personal hx.
In this example the billing is for F43.10 PTSD due to physical abuse, in
childhood: F33.2 Major Depression: and F41.1 GAD. While the Z code is
only meant to aid the Pt. in ct. understanding. As one can see the “F”
codes are no longer than 5 digits in length, and the with so many qualifying
“F” codes, the “Z” code in inconsequential to the billing process, but it is
import to the Pt.

12. What we need to know
While this section of the Dx.: F43.10 PTSD, F33.2 Major
Depression, and F41.1 GAD. states the reason for the ct.
needing services.
This section of the Dx. Abuse related to Z62.810 past
hx. of sexual abuse in childhood by so-and-so; is an
informational map needed by the Pt. to better
understand and service the ct’s. needs.
In the future, it is anticipated that the ICD 10 will have
no restrictions, but they are in the process of working out
the bugs at this time. In order to insure proper billing we
must follow these rules.

13. What we don’t say can cost us
• All of the Dx. for Mental Health and Substance
Use Disorder require the new specifier’s in order
to indicate severity. Mild, Moderate, or Severe.
• These specifiers help to identify the ct. level of
service, and are used to justify those services
rendered. Due to the over use of the NOS, in the
old DSM-IV-TR. County and most insurance are
now requiring specific identification of the ct.
service levels.

14. Specifier examples
• Mild, Moderate, and Severe are to be used in
almost all Dx. Any Dx. with multiple examples, for
instance:
• F33.o Major Depressive disorder, recurrent
episode, mild
• F33.1 Major Depressive disorder, recurrent
episode, moderate
• F33.2 Major Depressive disorder, recurrent
episode, severe without psychotic features
• F33.3 Major Depressive disorder, recurrent
episode, severe with psychotic features

15. Specifier examples con’t.
• For SUD it will look like this:
• Alcohol use disorder
• F10.10 …… Alcohol use disorder, Mild
• F10.20 …… Alcohol use disorder, Moderate
• F10.20 …… Alcohol use disorder, Severe
• Amphetamine use disorder
• F15.10 …… Amphetamine use disorder, Mild
• F15.20 …… Amphetamine use disorder,
Moderate
• F15.20 …… Amphetamine use disorder, Severe

16. House keeping!
When writing your Dx. be sure to write it exactly as it
states in the system. Why?
When billing Judy has a difficult enough time getting us
all paid, without having to look up the proper verbiage
to use in the Dx. part of the system. You will all receive
handouts with the proper codes and verbiage to keep
this process as simple as possible.
This verbiage is also professional and should be used
when writing out the Medical Necessity for Dr. Kalman.
Example: Due to the severity of the Dx. above, there is a
clear medical necessity for this ct. to receive services at
HP.
X Dr. Kalman

17. In closing
The current list of ICD 10 codes listed, are all working so far.
They have not all been tested and should something not
work, Judy and I will revise the list as needed and make sure
everyone gets the revised form.
If you find you need a code not on this list, this will mainly
occur with Mental Health, call myself or Judy and give us
the code so that we can get it into the system and verify it’s
ability to be used within the system.
I learned in an online training that, there are billing
instances where the use of the word Mild as the specifier is
resulting in the non-payment of billing. In this situation the
Pt. will have to go back and re-assess the specifier Mild, and
change that to Moderate or Severe in order to get paid.

18. QUESTIONS?
• I will do my best to get the answer if I do not
have it.

19. Additional books