July 2019

Pediatric Behavioral Health: Access and Coding Challenges

We want to offer more articles on behavioral health-related topics that may be of interest to our readers, based on feedback expressed during our annual newsletter survey. This article is the first in a series of articles written in collaboration with the Illinois Psychological Association. We hope you find the information relevant and useful.

According to studies, pediatricians and allied health care providers may have difficulty accessing behavioral health services for children and adolescents. To access services in the current system a child needs a diagnosis. Accessing evaluation services and classification are two of the most prevalent issues within pediatric/adolescent behavioral health. One contributing factor is the national shortage of child and adolescent behavioral providers (CABPs) (Kim, 2003). A second factor is that children remain difficult to diagnose (Regier et al., 2013, as cited in Cartwright et al., 2017).

Studies have found that neurodevelopmental periods are not well defined and are impacted by external stressors (Cartwright et al., 2017). Research has shown a significant percentage of children in the general population experience functional impairment but do not meet criteria for any DSM-V diagnosis. Functional impairment predicts outcome in later years, even if the threshold number of symptoms is not met (Costello et al., 1999).

While ICD-10 introduced more specific diagnostic codes, the behavioral health percentage of Not Otherwise Specified (NOS) diagnoses has not decreased (Møller et al., 2007, as cited in Cartwright et al., 2017). Overall, the limited ability of both DSM-V and ICD-10 to accurately classify children and adolescents with sub-threshold symptoms creates substantial challenges for CABPs. Thus, many children present with impairment that warrants treatment and cannot access it without a diagnosis (Cartwright et al., 2017). Without intervention, the risk of severe pathology increases 5-7 years later (Costello et al.,1999, as cited in Cartwright et al., 2017).

CABPs often must meet the needs of children within a challenging system. To do so, some providers may resort to reporting symptoms imprecisely. Up-coding is the practice of coding a more specific or more severe diagnosis than is reflected in a patient’s presentation, while down-coding is coding a broader, more general, or less severe diagnosis. When diagnostic criteria are not met, CABPs may be tempted to up-code to facilitate access to treatment within a family’s benefit plan (Cartwright et al., 2017). CABPs may be tempted to down-code a diagnosis to allow for further evaluation or ambiguity in symptom presentation. This practice may be problematic.

From an ethical perspective, CABPs are charged with helping those with whom they work and avoiding harm (APA, 2017, 3.04). Up-coding or down-coding may generate inaccurate descriptors of a child’s symptoms. CABPs must promote accuracy and honesty and avoid fraud or misrepresentation of fact (APA, 2017, 6.06). Additionally, CABPs have an ethical obligation to society and the community at large.

One reason that requirements to access treatment are stringent is because a limited amount of treatment exists. Some studies have shown imprecise or ambiguous coding practices may be more likely to occur when children are diagnosed with the following (Ruston et al., 2002, as cited in Cartwright et al., 2017):

Attentional disorders;
Depressive disorders;
Autism spectrum disorders (ASD); and/or
Learning disabilities.

These disorders also happen to be the most prevalent (Perou et al., 2013, as cited in Cartwright et al., 2017). A community cannot be well served if its resources are exhausted. So, when a child does not meet criteria for a specific DSM or ICD-10 diagnosis, how can an intervention occur within the patient’s health plan benefits? A helpful decision tree* is available in Cartwright et al., 2017, to offer guidelines for ethical decision making when criteria are not met.

To help address the lack of access to care, one step forward would be to increase access to providers that are within network. Blue Cross and Blue Shield of Illinois (BCBSIL) continues to recruit CAPBs across the state. When a CABP is not available to see a child, phone consultations with a specialist may enhance diagnostic accuracy and feasible access to care.

Given the challenges of the current diagnostic systems (DSM-V and ICD-10), CABPs can help by providing thorough documentation, which is essential to communication with other professionals. If additional subthreshold symptoms are present and not accounted for by a given diagnosis, this data should be provided via diagnostic specifiers, V-codes, a working or rule-out diagnosis, or elaborated upon in documentation.

CABPs are encouraged to facilitate substantial family involvement to support immediate and long-term progress of children and adolescents undergoing treatment. Families should be aware of the ways in which their child’s symptoms fall outside of a categorical diagnosis, so they may advocate for the unique needs of their child.

To help address pediatric behavioral health care challenges facing our members and their providers, we believe a team approach is needed. BCBSIL is committed to finding ways to help our members understand the importance of talking openly to their health care providers about behavioral health concerns. We want to increase awareness, so our members know how to find the right care at the right time and place. We appreciate the care and services physicians and behavioral care specialists provide to our members and their families.

*Included with permission of the American Psychological Association (APA).

References:
APA (2017). Ethical principles of psychologists and code of conduct. Retrieved from www.apa.org/ethics/code/index.aspx?item=3

Brown, T.A. and Barlow, D.H. (2005). Dimensional versus categorical classification of mental disorder in the fifth ed. of the Diagnostic and Statistical Manual of Mental Disorder and beyond: Comment on the special section. Journal of Abnormal Psychology, 114,551-556.

Caplan, P.J. and Cosgrove, L. (2004). Bias in psychiatric diagnosis. (pp.xix-xxxiii) Lanham, MD: Jason Aronson, Inc.

Cartwright, J., Lasser, J. and Gottlieb, M. (2017). To code or not to code: Some ethical conflicts in diagnosing children. Practice Innovations. Vol 2, No 4, 195-206. http://dx.doi.org/10.1037/pri0000053

Costello, E.J, Angold, A. and Keeler, G.P. (1999). Adolescent outcomes of childhood disorders: The consequences of severity and impairment. Journal of the American Academy of Child & Adolescent Psychiatry, 38, 121-128.

Frances, A. (2009). Essentials of psychiatric diagnosis: Responding to the challenge of DSM-V (rev. ed.). New York, NY: Guilford Press Publications.

Kim, W. J. (2003). Child and adolescent psychiatry workforce: A critical shortage and national challenge. Acad Psychiatry, 27, 277-282.

Møller, L.R., Sørenson, M.J., and Thomsen, P.H. (2007). ICD-10 classification in Danish child and adolescent psychiatry – have diagnoses changed after the introduction of ICD-10? Nordic Journal of Psychiatry, 61,71-78.

Perou, R., Bitsko, R.H., Blumberg, S.J., Pastor, P., Ghandour, R.M., Gfroerer, J.C., Huang, L.N. (2013, May 17). Mental health surveillance among children - United States, 2005-2011. Morbidity and Mortality Weekly Report, 62, 1-35.

Regier, D.A., Kuhl, E.A., and Kupfer, D.J. (2013). The DSM-5: Classification and criteria changes. World Psychiatry, 12, 92-98.

The material presented here is for informational/educational purposes only, is not intended to be medical advice or a definitive source for coding claims and is not a substitute for the independent medical judgment of a physician or other health care provider. Health care providers are encouraged to exercise their own independent medical judgment based upon their evaluation of their patients’ conditions and all available information, and to submit claims using the most appropriate code(s) based upon the medical record documentation and coding guidelines and reference materials. References to other third party sources or organizations are not a representation, warranty or endorsement of such organization. Any questions regarding those organizations should be addressed to them directly. The fact that a service or treatment is described in this material is not a guarantee that the service or treatment is a covered benefit and members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider.