Pediatric Coding Alert

Here’s how to make sure your pediatrician gets credit when no problem is found.

Here is a scenario that plays out every day in pediatric practices around the country. A mother brings in her infant and tells the pediatrician the child has been fussy and tearful and has been tugging on her ears. The pediatrician examines the child, but finds the infant is not running a fever and there are no problems with the ears.

In this scenario, how do you code when there is nothing wrong? See if you agree with the way our experts would do it.

First, Use Time to Get Credit for History and Exam

Even though your pediatrician found nothing wrong with the child, “you should still report the evaluation and management (E/M) code based on the amount of work performed and documented. In pediatrics, a noncommunicative child with vague symptoms often requires more of a history and exam to determine what is wrong with the patient,” advises JoAnne M. Wolf, RHIT, CPC, CEMC, AAPC Fellow, coding manager at Children’s Health Network in Minneapolis.

“This is not an uncommon scenario. Assuming the encounter documentation supports it, I would consider selecting an E/M level based on time,” suggests Jan Blanchard, CPC, CPEDC, CPMA, of Physician’s Computer Company in Winooski, Vermont. This solves the problem of getting credit for the time your pediatrician has spent on history and exam, which you can no longer use to select the office/outpatient E/M level. It also enables you to avoid assigning an extremely low-level E/M level based on MDM when there is seemingly no problem, and the pediatrician has not ordered or analyzed a test for the encounter.

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, which requires a medically appropriate history and/ or examination and straightforward medical decision making. When using time for code selection, 10-19 minutes of total time is spent on the date of the encounter.) or possibly 99213 (… 20-29 minutes of total time …), given the nature of the patient’s presenting problem.

Second, Know the Right Dx Code to Use

Without a definitive diagnosis, justifying billing an office/ outpatient E/M isn’t as easy as it looks. Fortunately, ICD-10 guidelines point to a combination of codes that should clear the way for payment.

“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,’” says Donna Walaszek, CCS-P, billing manager, credentialing/coding specialist for Northampton Area Pediatrics, LLP, in Northampton, Massachusetts.

The guidelines go on to clarify that “while specific diagnosis codes should be reported when they are supported by the available medical record documentation and clinical knowledge of the patient’s health condition, there are instances when signs/ symptoms codes are the best choices for accurately reflecting the healthcare encounter,” per guideline I.B.18.

“In this specific case, the child was brought into the office because an independent historian has reported fussiness in the infant. Code R68.12 (Fussy infant) is — and should be considered — a sign/symptom for the encounter and is the best choice for accurately reflecting the healthcare encounter given the lack of a definitive diagnosis,” Walaszek advises.

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 that the encounter was to reassure the parent and reduce caregiver anxiety.

Third, Know the Codes Not to Use

In a situation like this, “you may be tempted to look to an observation code, such as Z03.8 (Encounter for observation for other suspected diseases and conditions ruled out). However, ICD-10 guideline I.C.21.c.6. indicates that 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,’” says Walaszek.

The Bottom Line

In the end, “it is definitely good business practice to bill for all services rendered. Just because a child is not ill does not mean that it did not require your pediatrician’s expertise, based on years of expensive training, to determine that something serious is not going on. Payers will push back on everything that they can, but if you have documented care well enough to defend the claims you must report them,” cautions Blanchard.