What Code is Autism? Understanding the Complexities of Autism Diagnosis and Billing

The question of “What code is autism?” isn’t as straightforward as it might seem. Autism, a complex neurodevelopmental condition, is classified using different coding systems for various purposes. These codes are essential for diagnosis, billing, research, and understanding the specific needs of individuals on the autism spectrum. Let’s break down the key coding systems you’ll encounter:

ICD-10-CM Codes: The Foundation for Medical Diagnosis

The International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) is the standard diagnostic tool for medical purposes. It’s the system used by doctors, psychologists, and other healthcare providers to classify and code all diagnoses, including autism.

• F84.0: Autistic Disorder: This specific code is used to classify autistic disorder, previously considered the most severe form of autism. It indicates significant deficits in social-emotional reciprocity, including problems with back-and-forth conversations, sharing emotions, and responding to social interactions. This code is billable, meaning healthcare providers can use it for insurance reimbursement.
• 6A02: Autism Spectrum Disorder: This code is found within the WHO’s ICD-11 and reflects the more updated understanding of autism as a spectrum rather than a single disorder.
• F84.5: Asperger’s Syndrome: Historically, Asperger’s syndrome was categorized separately, though it is now considered part of the autism spectrum within the DSM-5. Individuals with Asperger’s were characterized by social interaction difficulties and repetitive behaviors but generally without significant language or cognitive delays like those seen with F84.0. It is important to note this code is no longer used as the diagnosis of Asperger’s syndrome was removed from the DSM 5. The F84.5 code would still be relevant in some legacy scenarios.
• F84.3: Other Childhood Disintegrative Disorder: This is a separate condition characterized by a regression in developmental skills and should not be confused with the autism spectrum.
• Shifting Classifications: The diagnostic landscape for autism has evolved. Prior to 2013, the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th Edition) used distinct categories like Autistic Disorder, Asperger Syndrome, and Pervasive Developmental Disorder Not Otherwise Specified (PDD-NOS). These have all been subsumed under the umbrella of Autism Spectrum Disorder (ASD) in the DSM-5, which is the current diagnostic standard.

CPT Codes: Billing for Services

Current Procedural Terminology (CPT) codes are used for billing and reporting medical procedures and services. These are critical for healthcare providers to receive proper reimbursement for their time and expertise. Here are some relevant CPT codes related to autism:

• 96110: Developmental Screening: This code is used for general developmental screenings and can also be used for autism screenings. This code is used for initial screenings.
• 96111: Developmental Testing; Extended: This code is used for longer, more comprehensive autism assessments conducted by physicians or psychologists. These assessments vary in length and detail and are used when more in depth testing is required.
• 92507: Individual Speech Therapy: This code is used by speech therapists for individual treatment sessions focusing on speech, language, voice, communication, and/or auditory processing.
• 92523: Evaluation of Speech Sound Production with Evaluation of Language: Used by speech language pathologist for speech and language evaluations.
• 92524: Behavioral and Qualitative Analysis of Voice and Resonance: Used by speech language pathologist when the evaluation focuses on the voice and resonance.
• 92526: Treatment of Swallowing Dysfunction: Used by speech therapists for individual treatment sessions for feeding therapy.

Understanding Autism Levels and Associated Codes

The DSM-5 recognizes that autism exists on a spectrum, with varying levels of severity and support needs. This spectrum is broadly classified into three levels:

• Level 1 Autism: Individuals at this level require support. They may have difficulty initiating social interactions and may struggle with some organizational and planning skills and inflexibility of behavior. This is often associated with what used to be called “high functioning autism” or Asperger’s Syndrome. The current coding for this level would be considered under the F84.0 diagnosis.
• Level 2 Autism: Individuals at this level require substantial support. They may have more difficulty with verbal and nonverbal communication, as well as restricted and repetitive behaviors that are more apparent.
• Level 3 Autism: Individuals at this level require very substantial support. They have significant limitations in verbal communication, may have very restricted interests, and may exhibit frequent repetitive behaviors. This is considered the most severe end of the spectrum.

Legacy ICD-9 Codes

While largely replaced by ICD-10, you might still encounter ICD-9 codes in older records or systems.

• 299.00: Autistic disorder, current or active state: This was the equivalent ICD-9 code to F84.0 from ICD-10.

Frequently Asked Questions about Autism Codes

Here are some commonly asked questions to further clarify the topic of autism codes:

1. What is the difference between F84.0 and F84.5?

   • F84.0 refers to autistic disorder which is characterized by significant social communication and interaction deficits, along with restricted and repetitive behaviors or interests. Historically this was associated with more significant language and cognitive impairments. F84.5 previously referred to Asperger’s Syndrome which involved similar social and behavioral challenges but with less severe or absent language and cognitive delays. It is important to note F84.5 is no longer used in modern diagnosis as Asperger’s is no longer considered a separate diagnosis in the DSM-5.

2. Can a child have both F84.0 and F84.5?

   • No, these codes cannot be used together. F84.0 and F84.5 are two different conditions according to the DSM-IV and earlier iterations of the ICD system. With the changes in the DSM-5, individuals previously diagnosed with F84.5 would be under the umbrella of F84.0, but now coded as Autism Spectrum Disorder with the appropriate level designation and/or with accompanying language or intellectual delay codes, if present.

3. What does “billable” mean in relation to the F84.0 code?

   • A billable code, like F84.0, indicates that healthcare providers can submit this code for insurance reimbursement for the medical services rendered.

4. What is the significance of the 6A02 code?

   • The 6A02 code refers to Autism Spectrum Disorder in the ICD-11. It aligns with the current understanding of autism as a spectrum rather than a discrete disorder.

5. How does the CPT code 92507 relate to autism?

   • CPT code 92507 is used by speech-language pathologists for individual treatment sessions focusing on speech, language, and communication skills, often a core area of need for individuals with autism.

6. Can CPT code 92507 be billed multiple times in one day?

   • No. According to Medicare’s Medically Unlikely Edits (MUEs), CPT code 92507 can only be billed once per day. This means that a single treatment session cannot be billed more than once, even if it’s an extended session.

7. What are CPT codes 92523, 92524 and 92526?

   • CPT code 92523 is used by speech language pathologist for a speech and language evaluation. CPT code 92524 is for a voice and resonance evaluation. CPT code 92526 is used for the treatment of swallowing dysfunction and feeding therapy. These codes are used for specific interventions related to autism.

8. What if an individual has symptoms of autism but doesn’t fit the exact criteria for F84.0?

   • If an individual does not meet the criteria for F84.0, the provider will use the code for ASD. Additionally, providers may also use other codes to indicate comorbidities, such as intellectual disabilities or language impairments.

9. Is autism considered a disability for tax purposes?

   • Yes, autism is generally considered a disability, and children with autism can be eligible for the Earned Income Tax Credit (EITC) and other tax benefits. There are specific guidelines to follow for claiming these benefits.

10. What are some federal laws that protect individuals with autism?

    • The most prominent law is the Americans with Disabilities Act (ADA), which ensures equal opportunities in public settings, employment, transportation, and more for people with autism.

11. What is the MELS Code 50 in relation to autism?

    • A MELS Code 50 is specific to educational support. In some regions or school systems, it indicates that a child with an autism diagnosis qualifies for additional support or accommodations at school.

12. How many levels of autism are there?

    • As defined by the DSM-5, there are three levels of autism (Level 1, Level 2, and Level 3), reflecting varying degrees of support needs.

13. What is “high functioning autism”?

    • “High-functioning autism” is not an official diagnostic term. Previously, this was a non-official term for those with diagnoses such as Asperger’s Syndrome. Typically, these individuals present within the Level 1 autism parameters.

14. Is there a “highest” level of autism?

    • Yes, Level 3 autism is considered the most severe and requires very substantial support for daily functioning.

15. How can I learn more about autism and its diagnostic criteria?

    • You can consult the DSM-5, the ICD-10-CM, and reputable organizations like the Autism Society of America and the National Institutes of Health (NIH). Additionally, consulting with medical professionals specializing in autism is recommended for accurate diagnosis and treatment.

Understanding the coding systems for autism is crucial for accurate diagnosis, appropriate billing, and accessing necessary support services. This guide offers a starting point for individuals and families navigating the complexities of autism. The specific codes used may vary depending on context, but understanding these foundational concepts will contribute to a more informed approach to autism care and support.