A Closer Look (continued)
What do you think contributed to the parents’ reluctance to follow through with the initial referral to a developmental-behavioral pediatrician?
Fear or anxiety about a possible diagnosis are sometimes so strong that parents do not follow through with recommendations for an evaluation. Comments from other family members that a child “is just going through a phase” or “is just like his uncle when he was a child, and he turned out fine” may discourage parents from pursuing further evaluation.
Financial considerations can also play a role.
What are the important messages from the PCP, including statements and tone, that you heard in this sample conversation?
- Recognizing the parents’ fear of the evaluation and their desire to normalize the unusual behaviors they have observed
- Noting there may be some differences in each parent’s level of concern
- Allowing for a variety of possible outcomes
- Explaining the screening tool (M-CHAT) is just that, and does not make a diagnosis
- Reassurance this will be a team effort
- Helping parents anticipate what the visit with the specialist will be like for them and their son
What does this sample dialogue teach us about how to address the parents’ reactions?
- Meets with both parents together
- Leaves space for questions, and matches affect to that of the parents
- Is honest about the limits of screening in her office
- Is open to hearing parents’ reactions to her suggestions
After a concerning screen, what language would you use with parents? Would you use the word “autism?” Would you use the word “failed?”
- It’s important that families understand what you are screening for without overly alarming them.
- Talk about the difference between a screening and diagnosis.
- Reassure parents that even if a child is diagnosed, he or she is the same child they know and love, with or without that label, but that the diagnosis may make it easier to get the child what he or she needs.
- “Failed” is a common medical term, but can be alarming for parents. Use words such as “concerning” to reflect the importance of results without unnecessarily increasing anxiety.
- Talk about specific concerns, like how the child’s trouble expressing what he wants and needs results in a lot of frustration for him and the parents. Identifying concerns like this will help lead to ways of addressing these challenges.
- “Autism” and “autism spectrum disorder” can be alarming for some parents at this phase of the process, while other parents may directly ask you about these terms. Use your knowledge of this family to determine if you should use these words.
- Reflect on your relationship with the family and use the strengths you know about this child as you discuss concerning results.
It sometimes takes a long time to talk with parents about results from a concerning screen or following an ASD diagnosis. Is it possible to bill for this time? What codes would you use?
Yes, you can usually bill for this time. This scenario typically falls under the Prolonged Services codes. This is a code series defining prolonged services by: Site of Service, Direct or Without Direct Patient Contact, and Time. It’s reported in addition to other physician services, including E/M services at any level. It includes the total time for a given date, even if the time is not continuous. The time must be 30 minutes or more.
Counseling parents about concerns following results from a screen or an ASD diagnosis from a specialist would likely be a preventive care visit. Consider the following codes:
|Face-to-Face||99354 first 30-74 min|
|Face-to-Face||99355 each additional 30 min >75|
|Before or After Face-to-Face||99358 first 30-74 min of non-face to face|
|Before or After Face-to-Face||99359 each additional 30 min >75|
Note: Billing and coding rules can change. Please check to ensure you are using the most current codes and guidelines