Blue Cross Reviewing Adjustment Disorders
By Barbara Griswold, LMFT (May 16, 2022)
Many Blue Cross network therapists around the country have received a curious correspondence from the Blue Cross Provider Education Department. The letter focuses on the therapist’s use of the Adjustment Disorder diagnosis.
If you got this letter, don’t panic. It is not one of those health plan letters you should be worried about. A few facts:
You aren’t being singled out. As I said, providers all over the country are getting this letter. Blue Cross told one provider that letters are being sent to therapists who used the Adjustment Disorder diagnosis for patients longer than six months for 5 or more patients.
Blue Cross repeatedly stresses that this is an educational letter. The fact that the Provider Education Dept is involved is good news — they aren’t the department that seeks to deny claims, asks for money back, or requests your notes.
We are not being asked to make changes. The letter states “we are not asking you to change the way you are treating your patients; we only want to promote the need for proper documentation.”
So what do they want? They only seem to want just a quick email response from you (just say you got their letter and give your NPI). In return, they will send you an educational email about Adjustment Disorders, and say they will note your response to the letter in their Provider Education database. The matter then seems closed.
“So, what are they wanting to educate me about?” The main thrust of the letter seems to be reminding clinicians when diagnosing a client with Adjustment Disorder “…to remain alert that this initial diagnosis may indicate a patient who is in the early phase of a major mental disorder. Therefore, if a patient continues to worsen, becomes more symptomatic, and does not respond to treatment, it is critical to review the patient’s symptom profile and confirm that the patient does not have an evolving major mental disorder.”
“Why are they doing this?” I’m not sure. They may really be concerned that we are using this “lighter” diagnosis and not noticing that something more significant is going on. Or maybe they are reminding us that once medical need for treatment no longer exists, we can’t keep using this diagnosis to seek insurance reimbursement.
“So, should I stop using the Adjustment Disorder diagnosis after 6 months?” Great question! Therapists sometimes think we can only use the diagnosis for 6 months. But read the criteria closely. The DSM-5 criteria includes the phrase “once the stressor or its consequences have terminated, the symptoms do not persist for more than an additional 6 months.” That means you start the 6 months when the stressor(s) or consequences have ended.
But what if the stressor goes on and on, or there are multiple stressors? According to the Mayo Clinic website, “persistent or chronic adjustment disorders can continue for more than 6 months, especially if the stressor is ongoing, such as unemployment” (hint: save this Mayo Clinic citation if needed to defend your diagnosis of a more chronic Adjustment Disorder). Other examples of a chronic adjustment disorder might be caring for a disabled child or dealing with a chronic illness. So, if you feel the client is still adjusting to a stressor after 6 months, and you don’t feel the client has a more severe diagnosis, I would use this diagnosis. Keep in mind, also, that it is possible that if you see a client who started treatment after one stressor and then months later was faced with a new stressor, I believe the clock would “restart” with the second stressor. So, a client might have lost a job and then months later lost their home and months later had to move back in with their parents — these sequential losses I think restart the 6-month clock each time.
Be sure to revisit diagnoses every 3-6 months to see if they need updating, changing, or additions. This way you feel confident if you are ever reviewed. Be sure that if clients no longer meet medical necessity criteria to address anxiety or depression and you are primarily just doing personal growth work that you change their diagnosis appropriately and explain you can no longer bill insurance.
As always, document the client’s symptoms and impairments in each session note as well as the medical necessity for treatment, in case you ever need to defend it.