Pediatric Coding Alert

A guide to reporting possible and obvious trauma cases

E/M and ICD9 Codes for child-abuse exams don't have to be uncharted water if you're following this rule of thumb: Report a mid- to high-level office visit and an observation, injury, sign, symptom or abuse code. 
 
Sometimes the abuse is obvious. Other times, a parent suspects abuse when none is found. Handling these difficult situations can prove emotionally trying without having to worry about the coding. 
 
To guide you through various reporting challenges, experts suggest strategies for coding the following four typical scenarios:

1. Parent Suspects Abuse, But None Found

For treating a possible abuse case with no findings, you may code the E/M based on time and use a diagnosis code that reflects the negative results.
 
A common scenario is the parent who shows up in your office on Monday morning after the child spent the weekend with the noncustodial parent, says Jeffrey Linzer Sr., MD, FAAP, assistant professor of pediatrics for the division of emergency medicine at Emory University School of Medicine in Atlanta. The mother says, "I just want to see if my son was abused." The pediatrician asks the child if anyone touched him inappropriately over the weekend and if anyone hurt him. The boy answers "No" to the questions. Upon examination, the pediatrician finds nothing - no signs of abuse whatsoever.
 
In this situation, the level of E/M code that you select will depend on the amount of time the physician spent talking to the child and the depth of the exam, Linzer says. While at a minimum, you could report 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...) for an expanded problemfocused history and exam, this type of suspected abuse would likely lead to a detailed history and exam and meet the requirements for moderate-complexity medical decision-making (99214). The time the pediatrician spent counseling and coordinating care could become the key component justifying 99215.
 
The visit may easily qualify as a level-five visit based solely on counseling time and coordination of care, says Victoria S. Jackson, the administrator and chief executive officer of Southern Orange County Pediatric Association in Lake Forest, Calif. Because counseling will likely dominate the E/M service, you may use time as the key element when determining the appropriate outpatient office visit level (99212-99215), she adds.
 
For an exam that results in no abuse findings, you should report V71.81 (Observation and evaluation for other specified suspected conditions; abuse and neglect) as a principle diagnosis, says Linzer, who is the American Academy of Pediatrics representative to the ICD-9-CM editorial advisory board. Payers shouldn't deny exams even though no findings occurred. "If an insurer rejects the E/M service, get on the phone and explain the situation," he says. Most insurance companies won't want to deal with the public-relations repercussions of not covering a child- abuse exam even if the exam resulted in no signs of abuse.

2. Injury Points to Abuse

When you deal with more obvious cases of physical abuse, you should report a higher-level E/M code and the appropriate diagnosis codes that describe the actual injuries.
 
For instance, a father brings his 11-month-old daughter in for a limp. He says, "The baby was just starting to pull herself up to a stand, but now she won't crawl." Upon examination, you find a femur fracture. With no history of trauma, this injury makes you suspect physical abuse.
 
You will probably report 99214 or 99215 for such a case, Linzer says. For the diagnostic coding, you could report 821.xx (Fracture of other and unspecified parts of femur ...) with the fourth and fifth digits representing the fracture's specific location, such as 821.01 for a closed femur shaft fracture.
 
Additional ICD-9 codes will depend on your other findings and expertise with the child's injuries and abuse. If, through investigation, you definitely feel that abuse occurred, you should report 995.54 (Child physical abuse) and add 821.xx to indicate the specific injury.
 
Whether you confirm or only suspect the abuse, state law requires you to make a report to the designated authorities. Even in the case of suspected abuse, you are not making an accusation when filing the report, Linzer says. Sometimes you may know that an injury is due to abuse, but you may not necessarily know who is responsible. In these cases, the authorities will determine who is responsible. But the information you provide with your history, exam and interpretation of findings will serve as a major guide in the investigation.
 
"If you're not positive abuse occurred, reporting a child-abuse code really brands the parents," Jackson says. The code will launch an investigation, in which a social worker will go to the child's house and may remove the child. But if you know that the child was abused, you must report the incident to the Child Abuse Registry, she says.

3. Suspicions Aren't Confirmed

Sometimes you may suspect abuse but not know for sure. Rather than coding the case as abuse, you may report the signs and symptoms that prompted the visit.
 
Suppose a mother brings her 6-year-old son in for behavior problems. She says that the child won't obey, even though she puts him in frequent time-outs and takes away privileges. Upon examination, you notice that the boy looks very thin and malnourished. He also has several welts from possible previous beatings.
 
"You will need to decide if the child's condition is due to neglect based on the information you glean from the history and physical," Linzer says. If you're not sure that  emotional/psychological abuse (995.51, Child emotional/psychological abuse) and neglect (995.52, Child neglect [nutritional]) occurred, you may report the signs and symptoms, such as underweight (783.22), malnourishment (263.9, Unspecified protein-calorie malnutrition) and/or contusions (such as 922.3x, Contusion of trunk; back), he says. But you still have a legal and ethical obligation to report suspected abuse.

4. Assault Is Obvious

When the abuse case is very clear-cut, you should use the abuse codes.
 
For example, a 12-year-old girl comes into your office and says that her stepfather raped her. A gynecological exam shows clear signs of sexual assault.
 
Based on the external examination, you'll probably report a level-five office visit. If you perform a colposcopy, you should also report 99170 (Anogenital examination with colposcopic magnification in childhood for suspected trauma), Jackson says. "Some payers may require modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) on the E/M code (such as 99215) to indicate that the evaluation and management exam is a significant, separately identifiable service from the colposcopy," she adds.
 
Most pediatricians, however, don't have the large-magnification equipment necessary to perform colposcopy in their offices, Linzer says. In this case, you may refer the patient to the emergency department, a rape and trauma center, or an ob-gyn for 99170.
 
To report the rape, you'll use 995.53 (Child sexual abuse), as well as an E code to identify the perpetrator, Linzer says. For rape by a stepfather, you would report E967.0 (Perpetrator of child and adult abuse; by father, stepfather, or boyfriend) as the second diagnosis on the claim form.