ABSTRACT. Background. In response to changing reimbursement and other pressures in the health care environment, many physicians have reported the use of alternate coding to substitute for certain clinical diagnoses. However, very little information is available on how physicians who care for children approach diagnosis and coding dilemmas for behavioral and mental disorders, which often present unique additional challenges.Objective. Our study sought to describe the frequency of alternate coding, different approaches to coding, and attitudes toward diagnosis and coding practices by physician specialty.Methods. We conducted a mail survey of 1492 physicians-497 developmental/behavioral pediatricians (DBP), 500 pediatricians (PED), and 495 child and adolescent psychiatrists (PSY). The main outcomes were survey items on frequency of alternate coding (never, rarely, monthly, weekly, daily), use of different coding strategies (use of somatic symptoms, modifiers, and substitution with other terms), and attitudes on coding practices (Likert scales of agreement). We analyzed outcomes by physician specialty and demographics using Pearson's 2 and multivariate logistic regression.Results. Overall response rate was 62% (787 of 1269 eligible physicians). The majority of physicians had used an alternate code (DBP 83%, PED 68%, PSY 58%), and many respondents reported monthly-daily alternate coding (DBP 60%, PED 36%, PSY 27%). Physicians used multiple approaches to diagnosis and a variety of coding options, which varied by physician specialty. Financial issues were commonly cited reasons for alternate coding-both to obtain patient services and to receive physician reimbursement. However, challenges of diagnostic classification and coding subthreshold symptoms were cited as frequently as reimbursement issues. Stigmatization, confidentiality, and parental acceptance were mentioned, but reported less frequently. Very few practices and providers have organized administrative methods of alternate coding (26%) or receive feedback on denied claims (46%). Most physicians believe that alternate coding is justified in the present system; however, some physicians expressed concerns that these practices may contribute to stigmatization or lead to improper management decisions.Conclusions. Alternate coding is commonly reported; however, approaches to diagnostic coding vary by provider specialty. Reimbursement issues are important, but other challenges in diagnosis and classification hold special relevance to children with behavioral and mental disorders. There seems to be a great need to reconsider the separate goals and uses of clinical diagnosis and administrative coding. Additional study is needed to assess how reported coding practices may affect administrative data, patient care, and health care economics. Pediatrics 2002;110(1). URL: http://www.pediatrics.org/ cgi/content/full/110/1/e8; diagnosis, medical practice management, reimbursement, medical records, insurance claim reporting, mental health services.

Considering effectiveness, safety, and tolerability, this literature review suggests that in adults there may be a lower association of weight gain and diabetes with ziprasidone, aripiprazole, and haloperidol as compared with olanzapine, clozapine, quetiapine, and risperidone. Youth may be particularly sensitive to weight gain, especially with olanzapine, as well as extrapyramidal side effects and metabolic changes. The literature suggests similar effectiveness among the antipsychotics, perhaps with the exception of clozapine having greater effectiveness, at least in adults.

In 1983 a scheme was run by the DHSS and the DTI whereby BBC microcomputers were placed in occupational therapy departments around Britain to see whether they would be a useful therapeutic tool. As part of this project Battle Hospital, Reading, was given two computers, one of which was intended to be peripatetic in the West Berkshire District. From December 1983to date one ofthe computers has been used at Fair Mile Hospital, Wallingford. This is a resulting report to show the possible uses of the BBC computer in psychiatry. It describes how the computer has helped to treat specific psychiatric symptoms and illustrates this with case observations to show the responses of various patients.

Community Child and Adolescent Psychiatry: A Manual of Clinical Practice and Consultation needs to be read and digested by every professional engaged in clinical services in community agencies and schools and should be required reading in every child and adolescent psychiatry residency training program. This book is a gem, loaded with critical information, laced with excellent clinical and administrative vignettes, enhanced by pertinent yet concise bibliographies, and written in a practical readable, non-cookbook fashion.

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