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Coding of pediatric behavioral and mental disorders
Jerry L Rushton1, Barbara T Felt, Mary W Roberts
1Child Health Evaluation and Research Unit, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan 48109-0456, USA. jrushton@umich.edu
Insights
Physicians frequently use alternate coding for behavioral and mental disorders due to reimbursement and diagnostic challenges. Practices vary significantly by specialty, highlighting a need to align clinical diagnosis with administrative coding.
Area of Science:
- Pediatric Health
- Medical Coding Practices
- Mental Health Diagnosis
Background:
- Physicians face healthcare pressures leading to alternate coding for clinical diagnoses.
- Limited information exists on how pediatric specialists handle coding for behavioral and mental disorders.
Purpose of the Study:
- To determine the frequency and approaches to alternate coding used by physicians.
- To explore physician attitudes towards diagnosis and coding practices across specialties.
Main Methods:
- A mail survey was distributed to 1492 physicians: developmental/behavioral pediatricians (DBP), pediatricians (PED), and child/adolescent psychiatrists (PSY).
- Survey outcomes included frequency of alternate coding, coding strategies (somatic symptoms, modifiers, substitutions), and attitudes via Likert scales.
- Data were analyzed by specialty and demographics using chi-squared tests and logistic regression.
Main Results:
- A high response rate (62%) was achieved, with a majority of physicians reporting alternate code use (DBP 83%, PED 68%, PSY 58%).
- Frequent alternate coding (monthly-daily) was reported by a significant portion of respondents (DBP 60%, PED 36%, PSY 27%).
- Reimbursement and diagnostic classification challenges were primary drivers, though stigmatization and parental acceptance were also noted. Few practices had organized administrative methods for alternate coding.
Conclusions:
- Alternate coding is prevalent but varies by physician specialty, particularly for pediatric behavioral and mental health conditions.
- While reimbursement is a factor, diagnostic classification complexities are critical for this patient population.
- Revisiting the distinct purposes of clinical diagnosis and administrative coding is necessary, with further research on the impact of current practices.
Background:
In response to changing reimbursement and other pressures in the health care environment, many physicians have reported the use of alternate coding to substitute for certain clinical diagnoses. However, very little information is available on how physicians who care for children approach diagnosis and coding dilemmas for behavioral and mental disorders, which often present unique additional challenges.
Objective:
Our study sought to describe the frequency of alternate coding, different approaches to coding, and attitudes toward diagnosis and coding practices by physician specialty.
Methods:
We conducted a mail survey of 1492 physicians--497 developmental/behavioral pediatricians (DBP), 500 pediatricians (PED), and 495 child and adolescent psychiatrists (PSY). The main outcomes were survey items on frequency of alternate coding (never, rarely, monthly, weekly, daily), use of different coding strategies (use of somatic symptoms, modifiers, and substitution with other terms), and attitudes on coding practices (Likert scales of agreement). We analyzed outcomes by physician specialty and demographics using Pearson's chi2 and multivariate logistic regression.
Results:
Overall response rate was 62% (787 of 1269 eligible physicians). The majority of physicians had used an alternate code (DBP 83%, PED 68%, PSY 58%), and many respondents reported monthly-daily alternate coding (DBP 60%, PED 36%, PSY 27%). Physicians used multiple approaches to diagnosis and a variety of coding options, which varied by physician specialty. Financial issues were commonly cited reasons for alternate coding--both to obtain patient services and to receive physician reimbursement. However, challenges of diagnostic classification and coding subthreshold symptoms were cited as frequently as reimbursement issues. Stigmatization, confidentiality, and parental acceptance were mentioned, but reported less frequently. Very few practices and providers have organized administrative methods of alternate coding (26%) or receive feedback on denied claims (46%). Most physicians believe that alternate coding is justified in the present system; however, some physicians expressed concerns that these practices may contribute to stigmatization or lead to improper management decisions.
Conclusions:
Alternate coding is commonly reported; however, approaches to diagnostic coding vary by provider specialty. Reimbursement issues are important, but other challenges in diagnosis and classification hold special relevance to children with behavioral and mental disorders. There seems to be a great need to reconsider the separate goals and uses of clinical diagnosis and administrative coding. Additional study is needed to assess how reported coding practices may affect administrative data, patient care, and health care economics.