ED Coding and Reimbursement Alert

Question: What diagnosis codes should we assign when a patient presents with a suspected problem, but no problem was ultimately identified? For instance, a pediatric patient was recently brought in because the mother thought he had swallowed a marble but, in actuality, that hadnt happened. Our physician performed an examination and noted that this was a well child exam. Is this correct?

Kansas Subscriber

 
Answer: Classifying cases like this as well-child visits is not appropriate. In fact, most payers strongly discourage the ED from being used for routine care. Instead, this situation should be coded with a code from the V71 category (observation and evaluation for suspected conditions not found). In this instance, V71.89 (observation for other specified suspected conditions; other specified suspected conditions) is most appropriate.
 
Use of these V codes indicates that there was a good reason to believe the patient required emergency attention, even if the outcome proved otherwise. In fact, notes describing this section of the ICD-9 manual explain that the category supports services to patients without a diagnosis or specific signs and/or symptoms, but who are nonetheless suspected of having an identifiable condition. These suspicions justify evaluation and observation, even if the condition is ultimately found not to exist.

If, in fact, the child had swallowed a marble, diagnosis code 935.2 (foreign body in mouth, esophagus, and stomach; stomach) would be appropriate to assign. In the case where some symptom is included in the suspected problem, then the symptom could also be coded. For example, if the mother said the child coughed earlier and that made her suspect the swallowed marble, then the cough (e.g., 786.2, cough) could be coded along with the V code.