Obtaining reimbursement for the treatment of sensory processing disorder may be tricky when a billable code to specify the diagnosis is a requirement. Certain classification systems may not even recognize the disorder—is the ICD-10-CM the code that legitimizes sensory processing disorder?
Sensory processing disorder (SPD) has an almost ghost-like presence in the medical world. Some doctors—mostly conventional—simply do not believe it is or should ever be a distinct disorder. Others seem almost frightened when parents mention their child’s meltdown triggered by the sound of a hoover.
With a mountain of evidence spelling out how just how severely sensory processing disorder affects children, why is there still so much scepticism? Some believe the exclusion of sensory processing disorder as a separate diagnosis in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM–5; American Psychiatric Association, 2013) may be behind some of the doctors’ persistent doubts.
The DSM-5 is used by professionals, mainly in the US, to diagnose mental disorders. The disorder not receiving it’s own listing in this influential manual may have far reaching consequences for treatment and access to appropriate interventions.
But what about international standards and classifications of diseases and health conditions? At first glance The World Health Organization’s International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) seems a little more inclusive of sensory processing conditions.
A diagnostic debate
The ICD-10-CM classification system refers to “Sensory integration disorder” as an “Approximate Synonym” under the F88 code: a billable/specific code that could be utilized to indicate a diagnosis for reimbursement purposes.
Does this legitimize sensory processing disorders, and does it mean the condition deserves a separate medical diagnosis? Many doctors believe sensory processing issues merely form part of the symptoms of recognized conditions and disorders like autism and attention deficit hyperactivity disorder (ADHD). Doctors along with researchers argue that there is simply not enough proof to confirm the existence of the condition according to scientific standards.
Such arguments do create a bit of a chicken and egg situation: if the condition is not legitimized will expensive clinical studies be funded and undertaken? And without such studies how will SPD ever be deemed worthy of a distinct and official medical diagnosis?
Many parents feel much needed SPD clinical studies will only receive research grants when it features prominently and distinctly in the professional manuals and classification systems doctors use and trust. Parents on the more sceptical side of the divide feel the natural treatments (which are mostly recommended for sensory processing issues) mean there is simply no financial incentive for pharmaceutical companies to spend money researching the condition.
Can the ICD-10-CM solve the debate by providing diagnostic codes for parents to obtain reimbursement for treatment? It seems the ICD-10-CM does not have an overall diagnostic code for sensory processing disorder. It does, however, have codes that may identify certain components of the condition. Sensory processing disorder may also fall within the scope of an “other condition” listed under the F88 code as mentioned above.
But before taking a closer look at some of these codes, it may be useful to define sensory processing disorder and examine its prevalence especially as it pertains to kids on the spectrum.
What is sensory processing disorder (SPD)?
Sometimes SPD is described simply as the brain not processing, or integrating, sensory inputs in the correct way. This may be oversimplifying a complex condition, one that many prefer to refer to as sensory processing differences rather than difficulties or disorder.
The fact remains; our current society is organized according to neurotypical standards which means the environment is often overwhelming to those who are hypersensitive, and underwhelming to individuals with hyposensitivity—it is important to note that those with SPD may be hypersensitive to certain stimuli and hyposensitive to others.
Kids with SPD battle to find balance; being at ease in their environment is a constant struggle which may lead to behavioral issues and learning difficulties. These children are either avoiding the brightness, loudness, and smelliness or they’re crashing into everything (or spinning endlessly) to just feel…something.
This is part of the controversy of whether SPD should be a separate medical diagnosis: is a child hyperactive or distracted because of sensory issues in the environment, or is it merely the manifestation of a condition like ADHD? Do severe sensory issues cause children on the spectrum to avoid social situations (leading to less opportunity to develop social skills) or should sensory issues be treated as just another symptom while adhering to scientific explanations of social deficits in autism? The debates about SPD are likely to continue and intensify, but at least there is finally recognition of sensory issues as a symptom of autism in the DSM-5.
The spectrum and SPD
The DSM-5 legitimized sensory issues as it relates to those on the spectrum by including it in the latest criterion for autism spectrum disorders (ASD). Hyper- or hypo-reactivity to sensory input or unusual interest in sensory aspects of the environment falls under the category of restricted, repetitive patterns of behavior in the diagnostic criterion for autism (DSM-5).
A study (Tomchek & Dunn, 2007) found that 95% of the sample of autistic children displayed some degree of sensory dysfunction. Parents and many occupational therapists agree that almost all kids on the spectrum process sensory stimuli differently to neurotypical peers.
The debates and quest to legitimize sensory processing disorder are not purely academic. The classification of disorders becomes important when parents have to deal with insurance, especially when the question of billable codes needed to specify a specific developmental disorder comes up. This is why parents sometimes accept an autism diagnosis even when they’re convinced their child has SPD; autism is a condition with codes ensuring reimbursement for treatments—even interventions relating to the sensory symptoms of being on the spectrum.
Your child’s therapist may be a good source of knowledge about codes and whether specific treatments will be reimbursed by medical insurers. Such experts may refer to the F82 and F88 billable codes in the ICD-10-CM; these codes may specify diagnoses encompassing symptoms of sensory processing and integration disorders.
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SPD and the ICD-10-CM code
The ICD-10-CM code F88 is used for a diagnosis of other disorders of psychological development. Therapists (such as occupational therapists who often treat symptoms related to SPD) often use this code because it applies to:
- Developmental agnosia
- Global developmental delay
- Other specified neurodevelopmental disorder. The approximate synonym “Sensory integration disorder” is found in this category
The use of this code may create difficulty as it is classified as an “other condition”. It is often easier to obtain reimbursements when a condition has a specific and distinct diagnosis and accompanying code. This may be the reason some doctors and occupational therapists recommend using other ICD codes to identify the components of sensory processing disorder most applicable to your child instead of vague “other condition” type codes.
For example the Hyperesthesia code (R20.3, ICD-10-CM) may be applicable if your child experiences atypical or increased sensitivity to stimulation. Many children on the spectrum benefit from occupational therapy for tactile hypersensitivity, if this specific symptom requires invention your occupational therapist will be able to assist with the applicable ICD code.
Some therapists believe conditions like dyspraxia (developmental coordination disorder) stem from SPD. An occupational therapist may design interventions to strengthen the sensory system, which may lessen the challenging symptoms related to dyspraxia. In this case the ICD-10-CM code F82 (Specific developmental disorder of motor function) may be appropriate.
A new code, ICD-11
With an understanding of the various billable codes, a bit of research, and help from your child’s therapist you may find codes used for reimbursement a little less intimidating. It is important to take note, however, that the new version of the ICD was released on June 18, 2018. It will become the official classification system used by member states commencing January 2022.
With each new round of revisions to the DSM and ICD, advocates hope that sensory processing disorder will get a distinct and legitimized medical diagnosis. The debates, the codes and the costs surrounding SPD may be distracting us from what is really important; helping children cope and be in control of their environment to ensure a better quality of life.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
Tomchek, S. D., & Dunn, W. (2007). Sensory processing in children with and without autism: a comparative study using the short sensory profile. The American journal of occupational therapy : official publication of the American Occupational Therapy Association, 61(2), 190–200. https://doi.org/10.5014/ajot.61.2.190.