Coding of medically unexplained symptoms and somatoform disorders by general practitioners – an exploratory focus group study

Abstract

BackgroundMedically unexplained symptoms (MUS) and somatoform disorders are common in general practices, but there is evidence that general practitioners (GPs) rarely use these codes. Assuming that correct classification and coding of symptoms and diseases are important for adequate management and treatment, insights into these processes could reveal problematic areas and possible solutions. Our study aims at exploring general practitioners’ views on coding and reasons for not coding MUS/somatoform disorders.MethodsWe invited GPs to participate in six focus groups (N = 42). Patient vignettes and a semi-structured guideline were used by two moderators to facilitate the discussions. Recordings were transcribed verbatim. Two researchers analyzed the data using structuring content analysis with deductive and inductive category building.ResultsThree main categories turned out to be most relevant. For category a) “benefits of coding” GPs described that coding is seen as being done for reimbursement purposes and is not necessarily linked to the content of their reference files for a specific patient. Others reported to code specific diagnoses only if longer consultations to explore psychosomatic symptoms or psychotherapy are intended to be billed. Reasons for b) “restrained coding” were attempting to protect the patient from stigma through certain diagnoses and the preference for tentative diagnoses and functional coding. Some GPs admitted to c) “code inaccurately” attributing this to insufficient knowledge of ICD-10-criteria, time constraints or using “rules of thumb” for coding.ConclusionsThere seem to be challenges in the process of coding of MUS and somatoform disorders, but GPs appear not to contest the patients’ suffering and accept uncertainty (about diagnoses) as an elementary part of their work. From GPs’ points of view ICD-10-coding does not appear to be a necessary requirement for treating patients and coding might be avoided to protect the patients from stigma and other negative consequences. Our findings supply a possible explanation for the commonly seen difference between routine and epidemiological data. The recent developments in the DSM-5 and the upcoming ICD-11 will supposedly change acceptance and handling of these diagnoses for GPs and patients. Either way, consequences for GPs’ diagnosing and coding behavior are not yet foreseeable.Electronic supplementary materialThe online version of this article (10.1186/s12875-018-0812-8) contains supplementary material, which is available to authorized users.

Episodes of care in a primary care walk-in clinic at a refugee camp in Germany – a retrospective data analysis

“…This could have caused the GPs to assign symptomatic diagnoses or note ‘no disease’ which was a predictor for longer care episodes in our analysis. It could be shown that GPs in a routine care setting were reluctant to diagnose a suspected underlying psychosomatic cause for the expressed complaints [ 32 ]. Therefore, the relatively low amount of mental health problems in our sample is likely an underestimation.…”

Diagnosis of somatoform disorders in primary care: diagnostic agreement, predictors, and comaprisons with depression and anxiety

“…This finding suggests that PCPs were aware of somatization in their patients, although not having labelled their patients as having a somatoform disorder. A recent qualitative study by our group among PCPs investigated the process of coding somatoform disorders in primary care [ 23 ]. In that study, PCPs reported that coding is done for reimbursement purposes, that they use other information in their personal documentation, for example about the patients’ psychosocial background or potential causes about the presented symptoms, and that they do not necessarily need to document a confirmed diagnosis for treatment.…”

“…Moreover, PCPs reported that they restrain their coding to protect patients from stigma trough certain diagnoses or other negative consequences. Inaccurate coding was further described to arise from uncertainties regarding the diagnostic criteria and that finding the definite diagnosis is seen as the responsibilities of psychiatric specialists [ 23 ]. Although we have not investigated these processes in the present study, it might be assumed that the described factors were of relevance among the PCPs in the present study and have contributed to the relatively low detection rate.…”

<p>Abdominal Epilepsy, a Rare Cause of Abdominal Pain: The Need to Investigate Thoroughly as Opposed to Making Rapid Attributions of Psychogenic Causality</p>

“…Further, the stigma associated with being diagnosed with a Somatoform Disorder or a Medically Unexplained Symptom (MUS) should not be understated. 5 One extremely rare cause of abdominal pain is abdominal epilepsy, also known as autonomic epilepsy. 6 The typical symptoms are idiopathic, paroxysmal-episodic abdominal and periumbilical pain caused by a central nervous system disturbance.…”