Pediatric Coding Alert

Sometimes diagnosis codes seem to get short shrift. Pediatricians, like most physicians, think that its the procedure codes that determine the reimbursement. For the most part, that is true. But, theres an uncomfortable trend taking root among insurance carriers, particularly managed care payers. Its called paying based on the diagnoses, instead of performed procedures. If the procedures of level of E/M code dont match the diagnosis code, in the payers opinion, then the claim is often downcoded or even denied.

To combat this, pediatric coders must ensure that they are listing the most specific ICD9 codes for the visit, and that they list all of the diagnosis codes that the visit covers.

Optimizing Office-Visit Coding

For example, you may find that a 99213 (level 3 office visit) with a diagnosis code for otitis media (385.82) is downcoded to a 99212 by the insurance company, says Donelle Holle, RN, reimbursement specialist for the University of Michigan Health System, Department of Pediatrics, in Ann Arbor. The child may have a raging fever, and the pediatrician may have had to do a CBC and a throat culture, says Holle. Whats the reason for a throat culture if the only diagnosis is otitis? To insurance carriers, there is no reason. So, you have to put down the diagnosis code for a fever as well. And its not only for testseven if the pediatrician sees that the ear is red and bulging, the doctor isnt going to stop there. The child must be examined. If the only diagnosis is otitis, you may find you are not getting adequately reimbursed, says Holle.

The answer is to use more than one diagnosis code. You can use up to four diagnoses per problem, emphasizes Holle. Pediatricians need to give the most information possible, because some companies are paying based on diagnosis codes. So, in the case of the otitis, you need to indicate what the child is presenting with. Here are two possibilities: 780.6 (fever) and 780.7 (malaise). Pediatricians often wont put the fever down, because they know its otitis, says Holle. But, we need to get everything on that claim.

Use 780 to 799.9

The codes for fever and malaise come from a section in ICD-9-CM that every pediatrician needs to look at, says Holle. This is the section on Symptoms, Signs and Ill-Defined Conditions and runs from 780 to 799.9. This section is essential for those situations in which you dont want to give a diagnosis youre unsure of, but you do want to be as specific as possiblea necessity under managed care.

Lets say a child comes in for frequent urination, says Holle. You do a dipstick and there is a little bacteria, but you need to do a clean-catch culture. How do you code the visit? You shouldnt use urinary tract infection (599.0) before you get the results of the culture, because that is why youre doing the cultureto find out. Instead, you can use a diagnosis code that is specific for the reason the child came in: 788.41 (urinary frequency).

Coding for Well-Child Visits

Its important to be as specific as possible in diagnosis coding, but sometimes a general code is the correct one to use. Take the case of well-child visits.

Robert Johannes, MD of KidsFirst Pediatrics, a two-pediatrician practice in Lakewood, CO, writes : We use V20.2 for children under one year old, V21.0 for 1 to 12 years, and V21.2 for 13 to 21 years. Is this correct? Johannes questions whether V20.2 is really the correct diagnosis code for all ages

V20.2 is the code to use for routine checks of children of all ages. This includes developmental testing, immunizations, and routine vision and hearing testing. The V21 codes are for constitutional states in development. V21.1 is for period of rapid growth in childhood. This is not a normal or routine situation. If a child grows four inches between the age of 13 months and 16 months, you may want to get this diagnosis into the record. V21.2 is for other adolescence, and again refers to body form, not to a routine check-up.

Sometimes you do need to be general, even in diagnosis coding.

However, you also need to do what the insurance company wants. We have heard of one plan that wants pediatricians to switch to V70.0 (routine general medical examination at a medical facility) for children over five.

Coding for Lab Tests

When ordering any kind of a test, it is difficult to know what diagnosis to use. Lee I. Hoffman, MD, managing partner of Childrens Medical Group, a six-pediatrician, three nurse-practitioner practice in Bloomfield, CT, expresses the problem this way.

What are appropriate codes to use for screening lab tests when ICD-9 codes are required on the lab requisition forms? We have been using the suspect condition code of V71.8 plus a diagnosis (e.g., hypercholesterolemia) but this is clumsy. I am reluctant to use a diagnosis that is not established. Some have suggested using just a well-child code. What would be most appropriate?

The answer depends on why the test is being done, says
Holle. Hoffman is correct in thinking he shouldnt use a code for a diagnosis until he is sure of the diagnosis. A well-child code wouldnt be appropriate either. Instead, use a diagnosis code that reflects the presenting problem. In the case of cholesterol, why is the child being tested? If, for example, it is because of a family history of high cholesterol, use V18.3 (family history of certain other specific conditions; other blood disorders), says Holle. The other possible code, V19.8 (amily history of certain other specific conditions; other condition), should be avoided because it is unspecific.

Follow-Up Visits and V67.9

Follow-up visits should get as specific a diagnosis code as possible. Elizabeth Banko, administrator of St. Peters Pediatric Faculty Group, a hospital-based practice in New Brunswick, NJ, writes to ask if the code for unspecified follow-up examination (V67.9) can be used for all follow-up office visits.

The answer is no. When youre following up on a diagnosis, you should put the original diagnosis for the re-checks, says Holle. Thats because that is what youre still treating.

For example, a parent may bring a diabetic child to the office for quarterly follow-up monitoring. Even if the patients blood glucose is within acceptable levels, you would still use a code for diabetes because this is what the child is being treated for.

There is another reason to avoid V67.9. Most, if not all, carriers will deny it because its too unspecific, she says.

Observation Codes

There are also two diagnosis codes for observation: V71.8 (observation for other specified suspected conditions) and V71.9 (observation for unspecified suspected condition). These are essentially the same codes, except that in one case, you know what youre looking for (V71.8) and in the other, you dont (V71.9), says Holle. Lets say a baby is born that might be septic, she says. You want to observe that child for possible septicemia, so you keep him in the hospital. Its always better to use V71.8, because it tells the carrier that you are looking for something specific (or several things), she notes. If I had to choose only one, I wouldnt use V71.9.

V71.8, like other codes for other specified suspected conditions, can be listed on the claim form first, with the specific problem code to follow. The first code acts as a modifier to the second to say, This is what I am looking for, not what the patient has. What you are doing is trying to rule the condition out.

Note: The April 1998 issue of PCA features an article (page 27) on the numbering of ICD-9 codes on the HCFA 1500 claim form.

Fussy Babies and Worried Moms

The big diagnosis dilemma for pediatricians is the fussy baby-worried mother question. Actually, this is only a problem if the pediatrician examines the child and finds nothing wrong.

What is the best code to use if an infant comes in very fussy and no known disease is found? A lot of times we have moms who think their child might have an ear infection, writes Brenda Smith, clinic supervisor for Southern Oregon Pediatrics, an eight-provider (six pediatricians, one PA, and one PNP) practice in Medford, OR. There is no fever and their ears are clear! Smith wants to know the best code to use to get reimbursed. The pediatrician has to think about what the child is presenting with, says Holle. There is always malaise (780.7). Go through the signs and symptoms codes (780 to 799.9) and find the diagnoses that most fit the presenting problem.

Another solution to the fussy-infant coding problem comes from Patty Watkins, coding and billing supervisor for West Texas Medical Associates, a multi-specialty group with four pediatricians in San Angelo, TX. It could be teething, she says. And, if thats what it is, theres 520.6. This is for disturbances in tooth eruption.

So, remember, if youre having a hard time getting a procedure code reimbursed, try to find a more specific diagnosis. And, use as many diagnoses as are applicable (up to four).