Wednesday, September 30, 2015

Welcome to ICD-10

Today is October 1, 2015, and the day set for the long-awaited change in the system used to code medical and surgical diagnoses.  Say good-bye to the 17,000 ways that the International Classification of Diseases 9 let you be sick or injured, and now we have 70,000 new ways for all those events.

In psychiatry, it shouldn't be too bad, and I'm planning to spend my day in the office updating my computer.  The psychiatry blogger PsychPractice was kind enough to make a cross-over chart, and I'm hoping that will be helpful.  If it might be helpful to you, here is the link:

For others, it may not be such an easy day.  If you're having angioplasty today, yesterday your doctor had a choice of one code.  Today, she has 845 options, so do be patient with her, it's a big menu to choose from.  

There were jokes on Twitter about codes that would differentiate between being bitten by a duck in a thong or being bitten by a duck while wearing a thong.  Here at Shrink Rap, where the duck has been our long-time mascot, we don't think that's at all funny.

If you'd like a sample of some of the new codes, however, there is something for everyone.

For the creative types:
Y93.D1 Activity, knitting and crocheting

For the more active souls:

V91.07XA Burn due to water-skis on fire, initial encounter

 For those who can be a bit klutzy:

T71.231D Asphyxiation due to being trapped in a discarded refrigerator, accidental.  I couldn't find the code if someone was trapped in a refrigerator that hadn't been discarded.

And for those who are just really unlucky:

V9542XA Spacecraft crash injuring occupant – 

The codes can be very specific:

S30.867A Insect bite (nonvenomous) of anus, initial encounter

And we don't want ClinkShrink to feel left out, so there is

Y92.146 Swimming pool of prison as the place of injury

(And I imagine ClinkShrink will certainly be spending her day checking on the safety features of all those swimming pools in the correctional system here in Maryland)

Finally, there really are duck-related injury codes and they are kind enough to differentiate whether the patient is struck by a duck W6162XA or bitten by a duck W6161XA.  I suggest that you not do anything to provoke the duck.

Monday, September 14, 2015


In case you missed it, the billboard above, sponsored by designer Kenneth Cole, has been the source of a lot of angst.  Presumably, Mr. Cole meant to point out that people with difficulties have trouble accessing mental health care ( ~so true), but instead the message blames people with mental illness for gun violence.  It's both wrong and stigmatizing, and the American Psychiatric Association understandably asked to have the billboard taken down and started a #GiveStigmaTheBoot campaign.

I want to point out an inconsistency in the APA's endorsements.  Representative Tim Murphy has proposed an overhaul of our national mental health services from the top down.  Many of Murphy's proposals in his Helping Families in Mental Health Crisis Act are admirable and have the potential to decrease repetition of oversight, and hopefully to change the way psychiatric services are delivered to those who need them most.  However, the bill was put forth in response to the Newtown tragedy where a disturbed young man killed 27 people, including 20 young children.  Murphy repeatedly says that something needs to be done about our nation's mental health services before more such tragedies occur, and that this is his promise to the parents of the children who died at the hands of a disturbed gunman.

Murphy's bill creates incentives for court ordering patients to outpatient treatment, also called Assisted Outpatient Treatment or AOT -- a measure that has been used in some states for people with psychotic disorders who are repeatedly hospitalized for noncompliance with treatment.  Outpatient commitment is a tough one -- it may help some people to get help, but it also infringes on a person's right to determine their own medical care, a civil right we all value.  
  In an article in Behavioral Healthcare on September 4, 2015, "Murphy touts mental health bill on Cleveland visit," Julie Miller writes about Murphy's support of the controversial outpatient commitment bill.   Miller writes:

He believes that if the perpetrators of violent tragedies like Sandy Hook Elementary School and the Aurora, Colo., movie theater had assisted outpatient treatment, the tragedies wouldn’t have occurred. To those who oppose AOT on the basis of personal freedom, he says, “Go talk to the moms from Sandy Hook and tell them that.”

Personally, I'm at a loss here.  From what I've read in a variety of sources: the media, the report of the Connecticut Department of the Child Advocate, and live-streamed testimony from the Aurora hearings, neither of those shooters had ever had a single psychiatric inpatient commitment and neither had a history of violence.  No one knew these young men had planned these atrocities.  The graduate student in Colorado was going voluntarily to treatment, he stopped when he left school and his eligibility for services ended.  If his psychiatrist knew he was dangerous, there are laws in place that would have permitted his commitment.  Both young men were diagnosed with anxiety disorders, not psychotic disorders, prior to their shocking crimes.  Simply put, they weren't candidates for Outpatient Commitment, and by making the assertion that outpatient commitment can prevent mass murders, the implication is that the government could knock on your door to see if you are harboring a loner young man who plays videogames and behaves oddly.  These aren't the people who get captured by Outpatient Commitment orders.

Yes, we need better mental health access and more comprehensive services.  But we need them to help people live better lives and suffer less.   Everything about Murphy's Bill as a promise to the parents of the children of Newtown --- that better mental health services will prevent mass murder -- is stigmatizing.   And yet the APA has no campaign against this stigmatizing bill, in fact, the APA wholeheartedly endorses this form of stigma.  

Tuesday, September 08, 2015

Follow Up on Parity and Tuition Reimbursement Insurance

I recently wrote a post about the discriminatory practices by Dewar Insurance -- a company that offers insurance for tuition reimbursement in case illness prevents a college student from completing the semester.  For some schools, the reimbursement is less and the standard of proof is higher if the illness is a mental disorder. 

The issue was originally brought to my attention by Maryland psychiatrist (and parent) Dr. Mark Komrad, author of  the book, You Need Help, wrote back with what he learned at freshman orientation at his son's college.  

A couple of weeks ago I discovered the lack of mental health parity in the tuition reimbursement insurance available through my son's college. And a few of us did research and found this parity problem common to many colleges, including in Maryland, but not all. Withdrawals for mental health reasons have tuition reimbursement at a lower percentage than "medical" withdrawals. Also, unlike medical withdrawals, mental health withdrawals require two days of hospitalization as part of the eligibility criteria to pay out.

I'm moving my son into college, and had a meeting about this with the directors of Student Accounts and a representative from the Dewar insurance company, the underwriters. I thought I would share some notes from that informative meeting:

  • -My son's school is on top of this issue and next year the tuition reimbursement insurance will have full parity for mental health, WITHOUT requirement of hospitalization!!!

  • -No family at this college has ever complained before about lack of parity until I raised this--neither prospectively as now, nor when a policy had to be used for mental health reasons! So there was no incentive to change, although the fairly new director of student accounts was troubled and was already taking initiative to change it before I got involved

  • -Only about 100 families buy a policy, most don't think they'll ever need it. So there is much interest here and elsewhere in making the policy automatically included as part of the bill next year, but with an option to opt-out. Like with all insurance, the more people who participate, the less expensive the premiums are.

  • --There has been a steep rise in withdrawal for mental health reasons nationally just in the last 4-5 years. The majority--about 70%-- of health withdrawals nationally now are for psychiatric reasons. Prior to that they were the minority reason. Nobody is quite sure why that is.

  • -Dewar would actually like to offer parity policies but many colleges have not been interested. Again, this is not a particularly popular product so colleges haven't paid much attention to the non-parity status quo that goes back several decades. Many are just starting to notice the non-parity issue now, and are moving to correct it. Dewar is happy to try and make that possible for any of its college customers.

  • --This policy places NO extra financial risk on colleges. That is NOT the reason colleges haven't sought parity.

  • -Dewar doesn't really challenge doctors notes vigorously. Docs have to fill out a form. There are no internal  "medical consultants" that review and deny coverage--unlike health insurance companies. With the policies that require psychiatric hospitalization, that requirement has been waved in many cases.  It's a holdover from many years ago when these policies were first crafted.

  • -For the business model to work for parity,  psychiatric (now the most common cause for intra-semester withdrawal) and medical can't BOTH be covered at 100%. So policies that now cover medical at 100% and psych at 60% will need to be restructured for the two the meet in the middle. Losing that 100% for medical may be one of the inhibitors to change

So, if we are going to go after this parity issue in Maryland, my sense is that it needs to be on a college by college basis to increase their consciousness about this issue, and, for those who have contracted with Dewar, to let them know that this can be potentially corrected.