Commentary: Health and Behavior Codes in a Pediatric Headache Program: Reimbursement Data and Recommendations for Practice

Abstract

Pediatric psychologists play an important role in pediatric hospitals as independent providers, consultants, and members of multidisciplinary teams in both inpatient and outpatient settings (Aylward, Bender, Graves, & Roberts, 2009). Psychological assessment and treatment often focus on psychosocial factors that contribute to a chronic or acute medical condition. Pediatric psychologists address child and family adjustment in the context of a child’s medical diagnosis in many ways, including by teaching coping skills for managing illness, pain, and associated emotional distress; helping patients improve adherence to medical regimens; and helping families support optimal child functioning despite illness. Thus, the primary presenting issue and focus of treatment is the child’s medical condition, and a mental health diagnosis may not be appropriate or justified in many children who are treated by pediatric psychologists. This shift in focus toward health behaviors and coping with medical illness, and away from traditional mental health diagnoses, has led to difficulties with reimbursement for pediatric psychology services (Mitchell & Roberts, 2004). Specifically, in the past, pediatric psychologists were required to bill for services using Diagnostic and Statistical Manual of Mental Disorders codes, resulting in a significant increase in the prevalence of ‘‘adjustment disorders’’ due to the use of this diagnosis to bill for pediatric psychology services (Rabasca, 1999). Health and behavior (H&B) codes were developed in order to address this issue by allowing pediatric psychologists to bill for assessments and interventions based on the child’s medical diagnosis. Pediatric psychologists in medical settings have been strongly encouraged to use H&B codes (see http:// www.apa.org/practice/cpt2002.html, http://www.apa.org /monitor/may06/codes.aspx, and www.apa.org/practice /cpt faq.html) to more accurately reflect the nature of services provided and to improve billing and reimbursement. Medical services are often covered by insurance, but psychology services, even as a component of a multidisciplinary team, are often covered by mental health carve outs if they are covered at all, resulting in lower rates of reimbursement. Billing an H&B code with a medical diagnosis sometimes allows for coverage within a patient’s medical benefits. Additionally, patients and their families may be more open to pediatric psychology services billed under a medical diagnosis, as opposed to a potentially stigmatizing and inaccurate mental health disorder. H&B codes became active in 2002, and it is unclear whether the use of these codes has improved reimbursement for pediatric psychology services, as anticipated. In 2004, the Society of Pediatric Psychology created a Task Force on Access for Patients to Clinical Services to evaluate reimbursement rates with H&B codes. Delamater, one of the chairs of the task force, conducted a web-based survey of pediatric and adult health psychologists in the United States regarding their knowledge and use of H&B codes (Delameter, 2004). Results indicated that although 90% of respondents reported knowing about H&B codes, only 44% used them at that time. Of those using the codes, the majority reported less than 50% reimbursement. Reimbursement was improved when the use of H&B codes was specifically explained to insurance companies. Denials were often due to the lack of pre-authorization for