EM Coding Alert

Question: A parent brings their infant to see the pediatrician, saying the baby had been fussier than usual and was tugging on their ears a lot. Upon examination, the pediatrician finds no problems and makes no diagnosis. How do I report this encounter if there is no diagnosis?

Florida Subscriber

Answer: In short, just because a child is not ill does not mean they did not require the expertise of the pediatrician. Determining something isn’t wrong can be just as valuable as determining that something is. This is a common scenario, and here are a few options:

Assuming the documentation thoroughly and accurately supports what happened during the encounter, consider reporting an evaluation and management (E/M) based on time. This will give your pediatrician credit for the time spent on the history and the exam without having to justify a low level that’s based on MDM when there was no problem and no tests ordered or analyzed. For a child already established to the practice, then, your code choices would include 99212 (Office or other outpatient visit for the evaluation and management of an established patient…10-19 minutes…) or possibly 99213 (… 20-29 minutes of total time …), depending on the extent of the exam and any questions or concerns the parent had.

However, as you know, payers want a diagnosis code to justify the E/M. Fortunately, per the 2022 general coding guidelines (I.B), “codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider.” The guidelines go on to clarify that “… there are instances when signs/symptoms codes are the best choices for accurately reflecting the healthcare encounter,” per guideline I.B.18. In the encounter you describe, the child was brought into the office because the parent, who can be considered an independent historian, reported fussiness in the infant. Code R68.12 (Fussy infant (baby)) is a perfectly viable sign/symptom for the encounter given the lack of a definitive diagnosis.

Coding alert: In addition, you should use Z71.1 (Person with feared health complaint in whom no diagnosis is made). The Z71 codes are used for “persons encountering health services for other counseling and medical advice, not elsewhere classified,” according to ICD-10 guidelines. The code implies the encounter was to reassure the parent and reduce caregiver anxiety.

However, using an observation code, such as Z03.8- (Encounter for observation for other suspected diseases and conditions ruled out) will not work in this scenario. According to ICD-10 guideline I.C.21.c.6., observation codes are “not for use if an injury or illness or any sign or symptom related to the suspected condition are present. In such cases the diagnosis/ symptom code is used.”