When neurologists diagnose functional neurological disorder, why don't they code for it?

Abstract

Objective:: Clinicians who recognize functional neurological disorders (FND) may not share that diagnosis with patients. Poor communication delays treatment and contributes to substantial disability in FND. Diagnostic (ICD-10) coding, one form of medical communication, offers an insight into clinicians’ face-to-face communication. Therefore, quantifying the phenomenon of non-coding, and identifying beliefs and practice habits that reduce coding, may suggest routes to improve medical communication in FND.

Methods:: We reviewed all pediatric neurology consultations in our hospital from 2017–2020, selecting those in which neurologists explicitly stated an FND-related diagnosis (N=57). We identified the neurological symptoms and ICD-10 codes assigned for each consultation. In parallel, we reviewed all encounters that utilized FND-related codes to determine whether insurers paid for this care. Finally, we assessed beliefs and practices that influence FND-related coding through a nationwide survey of pediatric neurologists (N=460).

Results:: After diagnosing FND, neurologists selected FND-related ICD-10 codes in only 22.8% of consultations. 96.2% of neurologists estimated that they would code for non-epileptic seizure (NES) when substantiated by EEG; in practice, they coded for 36.7% of such consultations. For other FND manifestations, neurologists coded in only 13.3% of cases. When presented with FND and non-FND scenarios with equal levels of information, neurologists coded for FND 41% less often. The strongest predictor of non-coding was the outdated belief that FND is a diagnosis of exclusion. Coding for FND never resulted in insurance non-payment.

Conclusion:: Non-coding for FND is common. Most factors that amplify non-coding also hinder face-to-face communication. Research based on ICD-10 coding (e.g., prevalence, cost) may underestimate the impact of FND by >4-fold.

Figure 1 –. Our methods for data acquisition, combining retrospective and survey methods

We assessed the behavior, beliefs, prior experiences, and attitudes of Neurologists regarding patients with Functional Neurological Disorder (FND) through paired assessments. We reviewed all inpatient consultations for a three-year period to identify cases in which the supervising physician made a diagnosis of FND, and then assessed whether they assigned FND-related diagnostic codes (ICD-10) for that encounter. We conducted a survey of US-based Pediatric Neurologists, including those physicians whose consultations we reviewed, to identify factors that influence a Neurologist’s decision about whether to utilize FND-related diagnostic codes. Finally, we compared physicians’ real-world diagnostic coding decisions with their stated beliefs regarding FND.

Figure 2 –. Self-identified reasons for not utilizing FND-related diagnosis codes

Neurologists were asked to recall a patient with suspected FND for which they did not utilize FND-related diagnosis codes. Respondents were asked to select all applicable reasons for not coding (could select none or multiple reasons, upper panel), and to also select the primary (most-important, lower panel) reason for not utilizing FND-related diagnostic codes. Potential responses included: concern for non-payment (insurance denial); concern that patient would be stigmatized by other healthcare providers; concern for the FND diagnosis being incorrect; difficulty finding the correct FND-related billing code; the practice style of only coding for symptoms, not underlying causes, until diagnostic testing is complete; concern about negative feedback from patient (including retaliation, bad reviews, or litigation).

Figure 3 –. Types of information provided in the clinical scenarios surveyed

Each of the six clinical scenarios we surveyed included a range of diagnostic information, allowing us to assess decision making under varying levels of clinical surety. Comparison of scenarios with identical types of information (e.g., epileptic seizure and non-epileptic seizure, both with supportive history but without EEG characterization) allowed us to identify factors associated with differential diagnostic coding between these scenarios.

Figure 4 –. Negative consequences after making an FND diagnosis

Physicians who responded that they had suffered negative consequences after making an FND diagnosis were invited to give examples of their experiences. These responses largely fell into a few categories, though some responses fit multiple categories of consequences.

Figure 5 –. Factors associated with non-coding for FND, and educational aims to counteract them

We assessed factors that were the primary drivers of non-coding when a neurologist diagnosed FND and identified specific educational interventions that may positively influence coding behaviors. We hypothesize that factors negatively associated with coding behaviors will also negatively influence clinician-patient communication in FND.