Changes in store for clinical social workers

black woman sitting at table looking at a huge stack of forms, with terms floating in the airLicensed Clinical Social Worker Camielle Call knows how daunting it can be to keep up with the changes in claim procedures that are taking place this year for those in her profession.

But she and other clinical social workers said thoroughly educating oneself on the revisions will make adapting to them much easier.

The claims and reimbursement processes that are changing include a revised CMS-1500 form; the International Classification of Diseases, 10th Edition, Clinical Modification (ICD-10-CM); the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5); and requirements to file quality measures from the Physician Quality Reporting System (PQRS).

Adjusting to what may seem onerous can be simplified by studying the changes, researching expectations from all avenues — including insurance companies — and revisiting obligations that social workers have to themselves and their clients, said Call, who has a private practice in Sitka, Alaska.

“We are the ones who are held accountable for the ethical and successful management of our practices,” she said. “We need not fear these changes; instead we can embrace them and utilize them to better benefit ourselves, our practices and our clients.”

NASW Senior Practice Associate Mirean Coleman said the DSM-5 and the ICD-10 are harmonized, and mental health providers now have one classification system for diagnosing mental illness.

The CMS-1500 form has been updated to accommodate the implementation of the ICD-10 codes. Clinical social workers are required to use PQRS measures in 2014 when filing claims for Medicare patients, she said, or they will be subject to a 2 percent penalty in 2016 for not using measures in 2014.

“It’s important for clinical social workers to remain on top of these changes and become familiar with deadlines so they can avoid reimbursement denials,” Coleman said.

NASW has created Practice Perspectives detailing the updates (see accompanying sidebar), and many NASW chapters have workshops and seminars planned to help clinical social workers familiarize themselves with the changes.

NASW member Doris Tomer, a clinical social worker in New York, said these modifications definitely impact whether claims are paid, what reimbursement will be and how long clinical social workers may have to wait to be paid for services rendered. By not staying informed, she said, “claims could be denied, and there may be some penalties.”

“It takes time (to adjust), which is in short supply when you are balancing many other professional and personal things,” Tomer said, adding that it is unusual to have so many changes happening at the same time.

Tomer said adapting to the PQRS requirements could prove to be the most challenging because clinical social workers are not used to performing quality measures.

The 2014 PQRS has 358 quality initiative measures, Coleman said, and each measure is assigned a measure number and title such as #248 (measure number) “Substance Use Disorders: Screening for Depression Among Patients with Substance Abuse or Dependence” (measure title).

CMS developed the measures to assess quality of care across all health care settings.

“Although this currently applies only for claims filed for Medicare reimbursement, it is possible other insurance companies may increasingly require this as well,” Tomer said. “It can help clinical social workers to check websites, and attend workshops and webinars to get themselves acclimated.”

Call will present a cursory review of the DSM-5 and the ICD-10 at the NASW-Texas spring symposium in Austin on May 16.

“As companion publications, they are to be used hand-in-hand as we diagnose — using the diagnostic criteria established in the DSM-5 — and then submit our billing for that diagnosis, using the ICD-10-CM,” Call said.

Ron Simon, executive director of NASW’s Pennsylvania Chapter, said the changes — especially with the correlation of DSM-5 and ICD-10-CM — are an opportunity for clinical social workers to become even more professional, although initially it may be challenging.

“With the streamlining of the DSM-5 and ICD-10-CM, it offers more fluidity,” Simon said. “The first challenge for clinical social workers will be to become subject matter experts as the mental health codes now correlate in both manuals. That will make them even more knowledgeable and professional.”

The streamlining of the DSM and ICD manuals also will help physicians and social workers to be on the same page when it comes to mental health diagnoses, said Lloyd Lyter, a professor of social work at Marywood University in Pennyslvania.

Lyter and his wife, Sharon, a professor of social work at the Kutztown University of Pennsylvania, regularly present workshops and lectures about the DSM-5 and have spoken on the subject at NASW’s Pennsylvania and New Jersey chapters.

“The ICD and DSM manuals have been correlating closer together over time,” Lyter said. “The point is to make the two more coordinated so the mental health codes can be used interchangeably by physicians and social workers.

“(Social workers) make up 45 percent of mental health providers in the U.S.,” he added. “It makes sense for us to use the same language as everyone else.”

NASW has developed Practice Perspectives to guide clinical social workers on the reimbursement process changes that will affect them in the coming months.

CMS-1500 Form

The revised CMS-1500 form, version 02-12, is a claim form used by clinical social workers to seek reimbursement for psychotherapy services. The use of the revised version takes effect April 1.

Clinical social workers can use either the revised form or the current one until March 31. The CMS-1500 form has been revised to accommodate the ICD-10-CM.


The ICD-10-CM identifies mental health diagnoses used by clinical social workers and other mental health providers.

On Jan. 16, 2009, HHS published a final rule adopting ICD-10-CM to replace ICD-9-CM in HIPAA transactions, effective Oct. 1, 2013. The implementation was then delayed to Oct. 1, 2014. The ICD system is used worldwide, copyrighted by the World Health Organization and maintained by HHS.

Clinical social workers can continue to use coding from the ICD-9-CM until Sept. 30 on the revised CMS-1500 form.


The DSM contains descriptions, symptoms and other criteria, and health care professionals use it as the authoritative guide to the diagnosis of mental health disorders.

According to the American Psychiatric Association, the DSM has been periodically updated since 1952, and the handbook is used to identify types of mental health disease.

The previous version, DSM-4, was last revised in 1994, said Mirean Coleman, senior practice associate at NASW. There have been a lot of changes in mental illness classifications since that time, she said.

The DSM-5 updates these changes. The mental health coding in DSM-5 is synchronized with the mental health coding in ICD-10-CM.

The DSM-5 will be helpful in measuring the effectiveness of treatment, as dimensional assessments will assist clinicians in assessing the level of treatment a patient may require.

The use of DSM-5 for clinical social workers will take effect Oct. 1. A DSM-5 workshop will be offered to all attendees at the NASW National Conference in July in Washington, D.C.


The PQRS, formerly known as the Physician Quality Reporting Initiative, consists of a set of health care measures that are identified by Medicare to determine the quality of services performed.

As of Jan. 1, clinical social workers must use the PQRS measures related to mental health when filing claims for Medicare patients. Failure to do so will result in a 2 percent penalty fee that will be applied in 2016.

The Centers for Medicare and Medicaid Diseases said the PQRS has been using incentive payments, and will begin to use payment adjustments in 2015, to encourage eligible health care professionals to report on specific quality measures.

NASW is preparing a Practice Perspective on PQRS 2014, which will be available this month and may be downloaded free from

Many NASW chapters are offering workshops and seminars to help educate clinical social workers on the DSM-5 and ICD-10-CM. Members are urged to check with their local chapter for a workshop in their area.

NOTE: The new 2017 Web site has moved many sections. Please check Clinical Social Work and Clinical Social Work Tools for these PDFs.