November 17, 2014

Autism – Clinical Documentation for Autistic Patients: Self-Care vs. Right Reimbursement

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I have written several articles for ICD10monitor over the years as we as an industry grapple with ICD-10 compliance. Like many of you, I have become a bit ICD-10-weary, but I have found a new breath of energy in the topic of autism and ICD-10.

Autism is a vague diagnosis to many, and the fact that there is a spectrum of symptoms complicates the clinical picture, and thus could complicate how ICD is applied. I am not going to attempt to be an expert on how to code a complicated diagnosis like autism, but I want to present the importance of the diagnosis to the 1-88 or 1-66 families of children, whichever statistic one chooses. I think it is important to look at where the World Health Organization (WHO) placed the ICD-10 code for autism more than 10 years ago, when the I-10 code was developed. It was a part of the mental health disorders, not a neurological diagnosis. ICD-10 was endorsed by the 43rd World Health Assembly in May 1990 and came into use in WHO member states as of 1994.

Obviously, there has been considerable research, and it continues today around the cause and symptoms and treatment for the children properly diagnosed with autism. Thus, it is critical to ensure the clinical record is documented in detail so the proper ICD-10/Diagnostic and Statistical Manual (DSM) codes are applied.

DSM defines a clinical picture that will require a comprehensive documented record to define autism:

Autism Spectrum Disorder
An individual must meet criteria A, B, C, and D:

A. Persistent deficits in social communication and social interaction across contexts, not accounted for by general developmental delays, and manifest by all three of the following:

1. Deficits in social-emotional reciprocity, ranging from abnormal social approach and failure of normal back-and-forth conversation through reduced sharing of interests, emotions, and affect, and response to total lack of initiation of social interaction.

2. Deficits in nonverbal communicative behaviors used for social interaction, ranging from poorly integrated verbal and nonverbal communication, through abnormalities in eye contact and body language, or deficits in understanding and use of nonverbal communication, to total lack of facial expression or gestures.

3. Deficits in developing and maintaining relationships, appropriate to developmental level (beyond those with caregivers); ranging from difficulties adjusting behavior to suit different social contexts through difficulties in sharing imaginative play and in making friends to an apparent absence of interest in people.

B. Restricted, repetitive patterns of behavior, interests, or activities as manifested by at least two of the following:

1. Stereotyped or repetitive speech, motor movements, or use of objects (such as simple motor stereotypies, echolalia, repetitive use of objects, or idiosyncratic phrases).

2. Excessive adherence to routines, ritualized patterns of verbal or nonverbal behavior, or excessive resistance to change (such as motoric rituals, insistence on same route or food, repetitive questioning or extreme distress at small changes).

3. Highly restricted, fixated interests that are abnormal in intensity or focus (such as strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests).

4. Hyper-or hypo-reactivity to sensory input or unusual interest in sensory aspects of environment (such as apparent indifference to pain/heat/cold, adverse response to specific sounds or textures, excessive smelling or touching of objects, fascination with lights or spinning objects).

C. Symptoms must be present in early childhood (but may not become fully manifest until social demands exceed limited capacities).

D. Symptoms together limit and impair everyday functioning.

I would argue the detail required for autism is vast and the skill needed for medical records review and code assignment requires a knowledge level greater than may be needed for other processes. The results of an inaccurate or inappropriate code applied are far-reaching, and could prevent a child and family from receiving opportunity for treatment and acceptance into the right program geared to the level of need. A child with special needs may not get access to care, as the services are already stretched beyond capacity and only paying customers get into ABA programs and social therapy groups, and receive special help in schools. They cannot get access to providers like dentists for routine dental care for special need patients, ophthalmologists for vision exams, and the list is long.

Autistic kids and adults are not behavioral or social misfits; they have a neurological deficit with a range of symptoms. Treatment is costly and often falls through the cracks. We as a nation have done poorly with meeting the needs of neurologically low-functioning people. This is not a short-term issue, but as the children are often diagnosed before the age of five and will continue to need many different modalities of treatment until end of life, one inappropriate code could make the difference that would resound over their lifetime.

So, understanding the clinical documentation, understanding the clinical picture for this huge population of our world (as this is not limited to the U.S.) could make a difference of this population being able to achieve self-care, with access to the right level of medical and mental health services. Unlike much of the clinical documentation, we directly correlate the right code to the right reimbursement level. ICD/DSM for the diagnosis is more about the correlation between attaining treatment from a very narrow segment of providers willing and able to treat the diagnosis of autism and the child receiving educational support to gain some level of success, which is important to many with the diagnosis.

The family commitment is great for families of the autistic child, who frequently are the only advocates a child may have, and having the appropriate diagnosis in the medical and school record can either open doors or lock them.

About the Author

Ellen VanBuskirk is the national director of healthcare practice with Slalom Consulting and has held executive positions in provider, payer, and managed care organizations. She started her career in clinical delivery with an expertise in emergency medicine. Ellen brings her expertise of working for many years on the U.K. National Health Service Modernization Program, as well as her experience of working on global and domestic healthcare program change for her clients.

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Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.
Ellen VanBuskirk

Ellen VanBuskirk is the national director of healthcare practice with Slalom Consulting and has held executive positions in provider, payer, and managed care organizations. She started her career in clinical delivery with an expertise in emergency medicine. Ellen brings her expertise of working for many years on the U.K. National Health Service Modernization Program, as well as her experience of working on global and domestic healthcare program change for her clients.