Is it possible to bill insurance for someone who has Adjustment Disorder for longer than 6 months? Will this be a red flag and trigger an audit? As is typical, when it comes to answers for psychotherapy – maybe and maybe not.
To understand the answer to this question, it’s necessary to know the definition.
DSM 5 Definition of Adjustment Disorder
Adjustment Disorder is a group of symptoms, such as stress, feeling sad or hopeless, and physical symptoms that can occur after you go through a stressful life event. The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM–5) defines Adjustment Disorder as “the presence of emotional or behavioral symptoms in response to an identifiable stressor/s, which occurred within three months of the beginning of the stressor/s. … “The distress is in excess of what would be expected from the exposure to the stressor and/or causes significant impairment in social or occupational (academic) functioning.” It lasts no longer than 6 months after the end of the stressful event. The symptoms go away when the stressor is gone or when the client learns healthy ways to cope. This is the definition of an acute adjustment disorder.
Given this definition, it’s not possible to bill for an adjustment disorder for longer than 6 months. If symptoms persist longer than six months, it’s wise to reassess the client’s symptoms to see if there is underlying anxiety or depression that the stressor exacerbated. If that is the case, change the diagnosis accordingly.
Persistent Adjustment Disorder
There is an alternative if the client does not meet the diagnostic criteria for another diagnosis. It’s now recognized that a person can have a persistent or chronic adjustment disorder that lasts for longer than 6 months. This is especially true if the stressor is ongoing. Some examples of ongoing adjustment disorders are unemployment, long term caretaking of someone who is chronically ill, and yes, adjusting to the presence of Covid-19. This means that it’s possible to bill for Adjustment Disorder for longer than six months!
Document. Document. Document.
Using Adjustment Disorder for long than six months can trigger an audit – but the findings don’t have to be bad ones. To fulfill the insurance company requirements, you need to justify the use of this diagnosis with a good clinical assessment and clear documentation.
For example, a client is raising a child with developmental disabilities. The child becomes an adult but is still unable to live independently. As the child’s developmental needs change, so does the adjustment the parent must make to the child’s ever-changing and complicated needs. This is a persistent Adjustment Disorder.
Passing an Audit
A few years ago I consulted with a therapist preparing a four-year retrospective Medicare audit. She was confident she had all the information but was concerned because her handwritten notes were difficult to read and too disorganized for an audit. So she learned my system and used my templates. She crossed every T and dotted every I, but we still worried she might fail the audit… because the client was diagnosed with Adjustment Disorder for FOUR YEARS.
However, in the process of transcribing her handwritten notes, she recognized and documented that the client had a major life stressor every year. The first year, the client, an immigrant, was adjusting to living in the US. The second year, the client was adjusting to getting a divorce. The third year, the client was coping with a significant illness. The fourth year, the client got into a new and good romantic relationship that she wanted to last. This therapist was able to justify medical necessity and to our delight, she passed the audit 100%.
So, yes, it is possible to diagnose a client with Adjustment Disorder for longer than six months if the stressors continue or new ones develop. Just document them because if you didn’t write it down, it didn’t happen.
If you want a quick and insurance-friendly way to document your case, Documentation WizardTM provides a streamlined process that cues you to include everything you need. Check out Master Clinical Forms. Or even better, you can become a Documentation Wizard through my online course, Misery or Mastery, and protect your income, pass audits, reduce your anxiety, and maintain your professional integrity.