When neurologists diagnose functional neurological disorder, why don't they code for it?

Lorena Doval Herbert, Rachel Kim, Asim A.O. Hassan, Alison Wilkinson-Smith, Jeff L. Waugh

Research output: Contribution to journalArticlepeer-review


Objective: Clinicians who recognize functional neurological disorders (FND) may not share that 25 diagnosis with patients. Poor communication delays treatment and contributes to substantial 26 disability in FND. Diagnostic (ICD-10) coding, one form of medical communication, offers an 27 insight into clinicians face-to-face communication. Therefore, quantifying the phenomenon of 28 non-coding, and identifying beliefs and practice habits that reduce coding, may suggest routes to 29 improve medical communication in FND. 30 31 Methods: We reviewed all pediatric neurology consultations in our hospital from 2017-2020, 32 selecting those in which neurologists explicitly stated an FND-related diagnosis (N=57). We 33 identified the neurological symptoms and ICD-10 codes assigned for each consultation. In 34 parallel, we reviewed all encounters that utilized FND-related codes to determine whether 35 insurers paid for this care. Finally, we assessed beliefs and practices that influence FND-related 36 coding through a nationwide survey of pediatric neurologists (N=460). 37 38 Results: After diagnosing FND, neurologists selected FND-related ICD-10 codes in only 22.8% 39 of consultations. 96.2% of neurologists estimated that they would code for non-epileptic seizure 40 (NES) when substantiated by EEG; in practice, they coded for 36.7% of such consultations. For 41 other FND manifestations, neurologists coded in only 13.3% of cases. When presented with FND 42 and non-FND scenarios with equal levels of information, neurologists coded for FND 41% less 43 often. The strongest predictor of non-coding was the outdated belief that FND is a diagnosis of 44 exclusion. Coding for FND never resulted in insurance non-payment. 45 46 Conclusion: Non-coding for FND is common. Most factors that amplify non-coding also hinder 47 face-to-face communication. Research based on ICD-10 coding (e.g., prevalence, cost) may 48 underestimate the impact of FND by 4-fold.

Original languageEnglish (US)
JournalCNS spectrums
StateAccepted/In press - 2021


  • Conversion disorder
  • Functional neurological disorder
  • ICD-10
  • Medical communication
  • Pediatric

ASJC Scopus subject areas

  • Clinical Neurology
  • Psychiatry and Mental health


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