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Feature  |   April 2014
Answers to Your DSM-5 Questions
Author Notes
  • Diane Paul, PhD, CCC-SLP
    is ASHA director of clinical issues in speech-language pathology. ■dpaul@asha.org
  • McCarty Janet, MEd, CCC-SLP
    is ASHA private health plans advisor. ■jmccarty@asha.org
  • © 2014 American Speech-Language-Hearing AssociationAmerican Speech-Language-Hearing Association
Article Information
Special Populations / Autism Spectrum / Language Disorders / Social Communication & Pragmatics Disorders / Feature
Feature   |   April 2014
Answers to Your DSM-5 Questions
The ASHA Leader, April 2014, Vol. 19, 56-58. doi:10.1044/leader.FTR3.19042014.56
The ASHA Leader, April 2014, Vol. 19, 56-58. doi:10.1044/leader.FTR3.19042014.56
There had always been uncertainty about the lines between diagnoses of autism, pervasive developmental disorder and Asperger syndrome—confusion the American Psychiatric Association sought to address when it collapsed the three diagnoses into the single autism spectrum disorder category in its updated Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition), released last May.
But new questions and uncertainty emerged with the introduction of the new social (pragmatic) communication disorder, distinct from ASD, and—more specific to speech-language pathology—with the renaming and revision of expressive and mixed receptive-expressive language disorders. And that’s not all: Other changes relevant to speech-language pathology treatment involve attention-deficit/hyperactivity disorder, intellectual disability, neurocognitive disorders and specific learning disorder.
A chart in the September 2013 Leader highlighted the major changes affecting SLPs and their clients, but the clamor for clarification continues. Here are responses to some of the many questions ASHA has received from members about the DSM-5 changes and effects on diagnosis and treatment.
Q How do the DSM-5 changes affect scope of practice and diagnostic issues? Will SLPs be able to diagnose SCD and ASD based on our battery of tests accompanied by clinical observation and functional performance?
DSM-5 does not change the speech-language pathology scope of practice. It remains to be seen how schools, payers and policy-makers will incorporate DSM-5 changes, if at all. Diagnosis of communication disorders, including SCD and ASD, was and continues to be within the scope of practice of SLPs—see page 66 for more specifics on this. And SLPs continue to diagnose communication, speech and language disorders related to any condition, including intellectual disabilities and specific learning disorder.
Q Are the terms “autism spectrum disorder” and “social (pragmatic) communication disorder” medical diagnoses?
The clinicians who can make the diagnoses in DSM-5 are not limited to medical professionals. Communication disorders , including ASD, are clearly within the domain of SLPs, who also contribute to related diagnoses, such as intellectual disabilities, specific learning disorder and selective mutism.
SLPs were involved in developing the criteria for communication disorders, including SCD. It was definitely that group’s intention that SLPs be the professionals to make the diagnoses included within the domain of communication disorders.
Q My understanding is that a child can have a social communication disorder and not have ASD, but if a child has ASD, she or he should almost always be diagnosed with a coexisting social communication disorder. Is that accurate?
To be diagnosed with ASD according to DSM-5, a child must have “persistent deficits in social communication and social interaction” and “restricted, repetitive patterns of behavior, interests, or activities.” Therefore, by definition, all children with ASD have deficits in social communication. However, children diagnosed with SCD have “persistent difficulties in the social use of verbal and nonverbal communication … ” but do not display the restricted, repetitive patterns. A child cannot have both diagnoses.
Q Asperger syndrome is no longer listed as a diagnosis under DSM-5. Can I still code that diagnosis and bill for the services I provide for Asperger patients?
DSM-5 groups all autism subcategories into a single category—autism spectrum disorder—and eliminates the diagnosis of Asperger syndrome. ICD (International Classification of Diseases)-9-CM and ICD-10-CM have not indicated if they will adopt the DSM-5 description of ASD, including the criteria parameters and the elimination of the term Asperger’s. We do know that Asperger syndrome remains in both the ICD-9-CM and ICD-10-CM, and that these are the HIPAA (Health Insurance Portability and Accountability Act) designated code sets for all third-party electronic billing and reporting. Therefore, SLPs can continue to code and bill for an Asperger diagnosis using ICD-9 and 10 codes. However, payers and policy-makers can make their own rules and now have new DSM-5 criteria to reference. Check with payers if there’s a question of which diagnosis system a payer follows.
Q The new DSM-5 social (pragmatic) communication disorder code isn’t included in ICD-9-CM or ICD-10-CM. Additionally, a person previously diagnosed with Asperger syndrome may now be diagnosed only with SCD. How will this change affect coding and billing?
The APA proposed a new code for SCD, which if accepted, will be effective in 2015, at the earliest. The new code will be found in the Mental, Behavioral, and Neurodevelopmental Disorders chapter, where you find the current 315 series of codes. How this will affect the status of Asperger syndrome as an ICD-10-CM diagnosis is unknown. Again, SLPs will need to check with payers on coverage for SCD, with or without an autism/Asperger diagnosis.
The coding and billing issues presented here may also affect school-based services, including Medicaid billing in the schools. Clinicians and families will need to check with school systems on service and payer changes due to DSM-5.
Q Will children who have SCD only still be able to receive services without formally getting a workup from a developmental pediatrician saying they do not have ASD? This could take additional months, and resources a family may not have.
SLPs are often the first professionals to see a child suspected of having ASD. SLPs can make this diagnosis, typically as part of a team. DSM-5 does not change the SLP’s critical role on the diagnostic team.
Q According to the diagnostic criteria for SCD, “The symptoms … are not better explained by autism spectrum disorder, intellectual disability ….” This seems like an untenable situation for an SLP: unable to diagnose a communication disorder because it calls for a negative finding of restricted and repetitive behaviors, which is a determination beyond the training and expertise of most SLPs. Yet aren’t SLPs supposed to be able to diagnose all communication disorders?
SLPs are expected to rule out ASD before making a diagnosis of SCD. Those SLPs who have expertise with ASD can make both diagnoses. Diagnosing ASD is within the scope of practice of SLPs, and this includes recognizing restricted, repetitive patterns of behavior. In fact, some of these behaviors may be directly related to communication, such as echolalia, idiosyncratic phrases or adverse response to sounds. Typically SLPs make such diagnoses as members of teams, but could make them independently if they have the requisite knowledge and experience.
Q Could the new DSM-5 diagnosis “unspecified communication disorder” be improperly used as a “parking place” by school districts, insurance companies and other service providers who would prefer not to provide the intensive early intervention a child with mild ASD might need?
It is preferable to select a specific diagnosis and support it with evidence rather than using the UCD category. If that cannot be done, the child is likely functioning within normal limits, and you could recommend a re-check in six months.
The UCD category was included for situations in which more specific information is not available to make a more definite diagnosis—for instance, if you can’t yet determine if a very young child meets criteria for a language disorder, speech disorder, ASD and/or other disorders. Because SCD is not diagnosed until 4 or 5 years of age, a child might start with UCD and then move into an SCD or other category. UCD also could be used later in life. SLPs should make a more specific diagnosis if a child meets the diagnostic criteria. Of course UCD should never be used as a way to delay or limit needed early intervention services.
Q Will the changes in the ASD category mean that children will not receive the services they need?
A recent study published in JAMA Psychiatry by the Centers for Disease Control and Prevention’s National Center on Birth Defects and Developmental Disabilities estimates that the number of children with ASD may be lower using the DSM-5 criteria than the DSM-IV-TR criteria (see bit.ly/dsm5asd). However, the study points out that other criteria may be used for a diagnosis, including history of developmental delay and intellectual disability.
The findings do not mean that children with communication problems and other challenges won’t receive the services they need. They might be diagnosed with SCD. What’s most critical is that children get the services they need regardless of the diagnostic label. Services should be based on a child’s individual strengths and needs.
For more information on DSM-5, visit on.asha.org/dsm5diagnose. For more practice-specific questions, contact Diane Paul, ASHA director of clinical issues in speech-language pathology, at dpaul@asha.org. For answers to coding questions, contact Janet McCarty, ASHA private health plans advisor, at jmccarty@asha.org. Readers are encouraged to share case studies that demonstrate the impact of the DSM-5 in their clinical practices.
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April 2014
Volume 19, Issue 4