Pediatric Coding Alert

Also: review the RSV testing codes.

One of the most common diagnoses that pediatricians see during the winter respiratory viral season is bronchiolitis, a disease primarily affecting infants and very young children. This is distinct from bronchitis, which is uncommon in pediatrics and more typically seen in adults. Respiratory syncytial virus (RSV) is the cause of the majority of cases of bronchiolitis, though other viruses can result in a similar clinical picture. RSV affects all ages but is most worrisome in the very young and the very old.

Illness severity can range from only mild nasal congestion to respiratory failure and death. This wide spectrum of disease severity creates significant challenges in assigning the proper evaluation and management (E/M), ICD-10, and CPT^® testing codes.

To help you figure it all out, let’s examine two scenarios.

Case 1: Your pediatrician meets with a 10-month-old established patient and her mother. The mother reports that the infant has had nasal congestion, sneezing, and a mild cough for three days along with low-grade fevers. The mother reports no episodes of labored breathing. The baby has had a slight decrease in appetite. The mother is worried because RSV is rampant in the daycare center the child attends. On physical examination, the child is alert and appears to be comfortable with no increased work of breathing. The pediatrician documents mild expiratory wheezers bilaterally. Office RSV test is positive. The pediatrician diagnoses the infant with bronchiolitis due to RSV and sends them home after giving the mother information on signs and symptoms of worsening disease severity that would warrant reevaluation. Treatment at home consists of nasal suctioning and administration of Tylenol as needed.

Let’s code this encounter.

ICD-10-CM code selection: Some pediatric offices do point-of-care testing for RSV while others do not. The diagnosis of bronchiolitis is often made on the basis of history and physical exam alone, and there is a specific diagnosis code to be used in that scenario: J21.9 (Acute bronchiolitis, unspecified). You will report the same diagnosis code when the physician tests for RSV and the test is negative as the patient’s bronchiolitis is due to a different virus not tested for. If the RSV test is positive, as in this case, you’ll assign J21.0 (Acute bronchiolitis due to respiratory syncytial virus).

E/M level selection: For a minimal degree of complexity, CPT^® describes a problem that “runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status.” Given the known potential for serious disease and the unpredictable course, no baby with bronchiolitis would fit into this category.

While deciding between limited and moderate complexity for bronchiolitis can be challenging, this case most likely represents an acute uncomplicated illness and, therefore, would be low complexity in this element.

The documentation of an independent historian with only one additional data point justifies no more than limited data in this element.

Treatment consisted of the recommendation for over-the-counter medication and instructions on how to properly perform nasal suctioning. You would choose low risk in this element for this case.

You would then select 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded.) as the proper CPT^® E/M code for case one given low complexity, limited data, and low risk.

Case 2: Your pediatrician meets with a 10-month-old established patient and her mother. The mother notes that the patient has had a cough, runny nose, nasal congestion, and low-grade fevers for three days. This morning the patient was having difficulty breathing. The child has been lethargic and hasn’t been eating as much as usual. There is nothing in the child’s history that is remarkable. On examination, the pediatrician notes that the child is breathing fast and with difficulty. She documents wheezing and crackles on examination of the chest. The patient’s oxygen saturation is low. Office RSV test is positive, and the pediatrician diagnoses the child with acute bronchiolitis due to RSV. Then follows a documented discussion between the pediatrician and the mother about the possible need for hospitalization. The doctor states “This baby is on the fence for admission to the hospital.” After shared decision making, they agree the infant will go home with the mother who will watch very closely for worsening of the infant’s condition. A follow-up appointment is scheduled for the next day. The pediatrician then instructs the mother to administer Tylenol as needed and review the proper method for nasal suctioning for symptom relief.

Let’s code this encounter.

ICD-10-CM code selection: You would begin with the same selection of J21.0 as the RSV test is positive. Case two, on the other hand, describes a significantly sicker child with lethargy, difficulty breathing, and low oxygen, or hypoxia (R09.02, Hypoxemia). Hypoxia should be added as a second diagnosis code.

E/M level selection: The presence of hypoxia places this case more appropriately into an acute illness with systemic symptoms, or a moderate level in the complexity element. The documentation of an independent historian with only one test ordered justifies no more than limited level in the data element.

For case two, the risk element level may be determined by documentation of whether the pediatrician discussed potential hospitalization of the baby given low oxygen. In cases like this, a decision to hospitalize is often determined by just how low the oxygen level is and how comfortable the physician and family are with continuing to observe the baby at home given the known risk for deterioration. A high risk element level is the appropriate choice in case two since possible hospitalization was documented.

The proper CPT^® E/M code for case two would be 99214 (… moderate level … 30 minutes ...) for moderate complexity, limited data, and high risk.

Remember the Testing Codes

In order to bill for the RSV test itself, you must know which type of point of care RSV test the office uses. Most offices will use 87634 (Infectious agent detection by nucleic acid (DNA or RNA); respiratory syncytial virus, amplified probe technique). However, other offices will use 87807 (Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; respiratory syncytial virus).

David Cahill, MD, Pediatrician, Akron Children’s Pediatrics, Lisbon, Ohio