Pediatric Coding Alert

Question: Our office treats several children with behavioral problems. We use diagnosis code 312.9 (unspecified disturbance of conduct). Several insurance companies are refusing to pay. Can you give us some assistance or a better diagnosis code? If we use 312.9 with another diagnosis, most claims are paid, but 312.9 alone isnt paid.

Utah Subscriber

Answer: The problem may be that these insurers have carved out mental-health services to certain, specific mental-health providers. Therefore, all 300 series diagnosis codes are automatically rejected. The best solution is for you to talk to the insurance companies. They may need to certify you to provide mental-health care, even though this is a common, everyday part of pediatric practice. Some insurance companies may insist that they have already paid for this service under their mental health carve-out and will not pay you. In that case, you have to decide whether to treat patients with that insurance for these problems or refer them to someone on the panel of mental-health professionals who have already been paid to provide this care. Sometimes this is a hard choice, but you need to get the patient care while maintaining a financially viable practice. Approach the insurance companies. You may be pleasantly surprised at how many will work out a way for you to see these patients once they understand that this is part of the service that a full-service pediatrician offers. (For more on this topic, see article on counseling for violence prevention, page 36.)