Rushton Jerry L, Felt Barbara T, Roberts Mary W
Child Health Evaluation and Research Unit, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan 48109-0456, USA.
Pediatrics. 2002 Jul;110(1 Pt 1):e8. doi: 10.1542/peds.110.1.e8.
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.
Our study sought to describe the frequency of alternate coding, different approaches to coding, and attitudes toward diagnosis and coding practices by physician specialty.
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.
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.
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.
为应对医疗环境中不断变化的报销政策及其他压力，许多医生报告称使用替代编码来取代某些临床诊断。然而，关于照顾儿童的医生如何处理行为和精神障碍的诊断及编码困境的信息却非常少，而这些障碍往往带来独特的额外挑战。
我们的研究旨在描述替代编码的频率、不同的编码方法以及不同专业医生对诊断和编码实践的态度。
我们对1492名医生进行了邮件调查，其中包括497名发育/行为儿科医生（DBP）、500名儿科医生（PED）和495名儿童及青少年精神科医生（PSY）。主要结果是关于替代编码频率（从不、很少、每月、每周、每天）、不同编码策略的使用（使用躯体症状、修饰词以及用其他术语替代）以及对编码实践的态度（李克特同意量表）的调查项目。我们使用Pearson卡方检验和多变量逻辑回归按医生专业和人口统计学特征分析结果。
总体回复率为62%（1269名符合条件的医生中有787名回复）。大多数医生使用过替代编码（DBP为83%，PED为68%，PSY为58%），许多受访者报告每月至每天都进行替代编码（DBP为60%，PED为36%，PSY为27%）。医生采用多种诊断方法和各种编码选项，这些因医生专业而异。财务问题是替代编码的常见原因——既为了获得患者服务，也为了获得医生报销。然而，诊断分类和对阈下症状编码的挑战与报销问题被提及的频率一样高。还提到了污名化、保密性和家长接受度，但报告频率较低。很少有医疗机构和提供者有组织替代编码的管理方法（26%）或收到关于被拒赔申请的反馈（46%）。大多数医生认为在当前系统中替代编码是合理的；然而，一些医生担心这些做法可能会导致污名化或导致不恰当的管理决策。
普遍报告了替代编码的情况；然而，诊断编码方法因提供者专业而异。报销问题很重要，但诊断和分类中的其他挑战与行为和精神障碍儿童特别相关。似乎非常有必要重新考虑临床诊断和行政编码的不同目标及用途。需要进一步研究以评估报告的编码实践可能如何影响行政数据、患者护理和医疗保健经济学。
