Documentation Decisions: The Ethics of Diagnostic Codes for Children Professional division exists within behavioral health when considering the utility of recording diagnostic codes for child patients. Researchers are investigating anew the clinical utility of traditional diagnostic criteria, namely the criteria found in the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Classification
Others contend that providers need adequate diagnostic criteria that will assist them in properly obtaining services for children, and that an ethical means of currently doing so is sorely lacking (Cartwright & Dryden, 2022). Alternatively, there is clinical concern that imprecise coding can overly pathologize a child or adolescent, leading to additional problems for the young person, namely undue identification with diagnostic criteria during developmental periods of identity formation, which is usually a phenomenon for adolescents. In other words, the adolescent can begin to wrongly adopt the behaviors and attitudes of a diagnosis, thus creating a maladaptive identity. In this example, imprecise coding has severely backfired, causing undue harm for the adolescent in question. Additionally, according to Cartwright (2018), “[I] f unnecessary or inaccurate, a diagnosis may cause more harm than good. An inaccurate diagnosis would give caregivers and professionals misleading information and it may add unnecessarily to stigma placed on a child, among other dangers” (p. 198). Given the reality that children and families will only receive treatment with an appropriate coding diagnosis, regulated by third-party payors, Cartwright (2018) argues that providers face ethical dilemmas that potentially justify the use of imprecise coding in order to secure treatment services for children and families, who would otherwise have no financial ability to pay for services of this kind. The authors continue with the claim that while this imprecise coding may serve the child, it is nonetheless a misrepresentation by the clinician and therefore a form of fraud and thus illegal and unethical. Clinicians face difficult decisions when considering how to diagnose children correctly and acknowledge that “down-coding may be justifiable at times as a conservative approach within a flawed diagnostic classification system. When there are too many factors to consider and not all factors can be accounted for at the time of the diagnosis, down-coding to a broader, less severe diagnosis, or unspecified diagnosis, may be an ethical and appropriate alternative” (Cartwright, 2018, p. 204). Of course, when children meet the full criteria for a specific DSM diagnosis, the ethical problem disappears and children are able to receive the treatment they need. Overall, the authors recommend that providers adhere to an objective approach, balancing the needs of children and families against their ethical and legal requirements to code accurately. A carefully created objective client record serves the combined needs of the child, other involved providers, and third-party payors. integrated care reflects the awareness that behavioral care is necessary and specialized, and that various providers need documentation that is accurate and standardized (Bruni et al., 2021; Chowdhury & Champion, 2020; Hosang et al., 2022; Reiter et al., 2018). Integrated care settings typically offer healthcare and behavioral care in one facility or on one campus, allowing patients to have easier access to services and providers. Typically, these care models utilize an electronic health record (EHR) that contains all pertinent healthcare information for each patient. Providers also typically collaborate to improve access to care, and they coordinate care across varying services for patients (Kariotis et al., 2021; Meeder, 2021). However, the integration of services creates a complexity of documentation sharing and related ethical issues for behavioral providers that manifest in the creation
of Diseases (ICD). These authors are investigating the usefulness of alternative diagnostic criteria that identify mental health and mental illness as being found within a continuum of functioning and circumstances, not within the circumscribed categories that are often associated with the DSM and the ICD (Cartwright, 2018). Cartwright highlights the concern, stating that “clinicians have recognized that the current categorical approach implies a discontinuous nature of mental health and does not allow recognition of the full spectrum and complexity of psychiatric disorders” (Cartwright, 2018, p. 196). According to Cartwright (2018) , ethical decisions abound when considering diagnostic decisions because “children are especially difficult to diagnose given that neurodevelopmental periods are not specifically defined, development among children varies widely, symptom patterns are difficult to detect within a short history, and children are reactive to family and environmental stress” (p. 196). Specifically, this problem is evident when clinicians, using categorical diagnostic criteria, try to ascertain if children’s behavior and symptomatic presentation are within normal ranges, subacute, or abnormal and severe. A 2002 survey of 495 child and adolescent psychiatrists, 497 developmental and behavioral pediatricians, and 500 pediatricians sought to understand the coding decisions made by this group when assessing, diagnosing, and treating children and adolescents. Nearly 70% of the respondents said they engage in routine imprecise coding, namely up-coding or down-coding. The practice of up- coding is a diagnostic method of exaggerating the severity of the presenting symptoms, whereas down-coding is a diminishment of the clinical symptoms when documenting a diagnosis (Rushton et al., 2002). The study revealed that providers most frequently reported down-coding, typically more than 75% of the time, and that the primary reason for imprecise coding was to help clients gains access to services reimbursed by a third-party payor source. According to Cartwright (2018), “[C]linical examples include up-coding in the public school system to facilitate access to special education services; down- coding to an adjustment disorder in a teen; up-coding to ASD rather than social communication disorder in order to receive reimbursement for specific treatment” (p. 197).
Documenting Behavioral Practice within Integrated Care Systems The contemporary healthcare landscape continues to evolve in the direction of greater inclusion of behavioral providers in primary care (Riley & Freeman, 2019). Thus, integrated healthcare settings have greatly expanded in Western nations, with providers reporting preferences for integrated treatment teams (Lancaster et al., 2018). This is due, in part, to the introduction into law of the Patient Protection and Affordable Care Act, which was enacted in 2010 (Maniss & Pruit, 2018), although the roots of integrated care delivery go back as far as the 1930s. Today, integrated care practices are commonly offering “deliberate
and sustained coordination of care among health care practitioners (physicians, nurses, nurse practitioners, and physician assistants, among others) and behavioral health professionals (social workers, psychiatrists, psychologists, mental health counselors, and addiction specialists, among others)” (Reamer, 2018, p. 118). This growth of
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