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MANAGED CARE Q&A

Our small pediatric practice has tremendous difficulty securing adequate reimbursement for pediatric visits for psychosocial problems. What methods can we use to ensure hassle-free payment?

In order to combat inadequate reimbursement of pediatric psychosocial services from managed care organizations (MCOs) and insurance companies, assign the appropriate Current Procedural Terminology (CPT) code, utilize The Classification of Child and Adolescent Mental Diagnoses in Primary Care — Diagnostic and Statistical Manual for Primary Care (DSM-PC), Child and Adolescent Version, justify your work and negotiate your strengths.

Health plans have argued for years that the generic terms used by pediatricians to describe "behavior problems" or "adjustment reaction" are vague and inaccurate. The DSM-PC answers this concern. MCOs are familiar with these diagnostic codes and have actuarial expectations of appropriate services. An added feature of DSM-PC is the ability to code for problem situations and behavior diagnoses using the developmental variation and minor problem codes. This is especially important because many of these psychosocial problems do not reach the level of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).