Pediatric Coding Alert

The pediatrician diagnoses gastroenteritis and orders a stool test to determine whether the condition’s origin is viral, bacterial, or parasitic. They note that without more information on origin, the risk for complications are significant and prescribe an oral rehydration solution in the meantime and instruct the mother to bring in a sample later that day and bring the child in for a follow-up in 3 days.

Condition refresh: Gastroenteritis is an inflammation or infection of the gastrointestinal tract, primarily affecting the stomach and intestines. It is commonly caused by viruses, bacteria, or parasites.

Visit 2: At the follow-up, the child’s diarrhea and vomiting have improved, but the abdominal pain and low-grade fever are still present. The child appears less dehydrated and lethargic than during the initial visit. The stool test indicates that the gastroenteritis is caused by a viral Norovirus infection.

The pediatrician replaces the oral solution with advice to increase regular fluid intake and offers hand-washing advice as well as a common brand of over-the-counter (OTC) fever reducers, then downgrades the risk from high to low.

Report the Right ICD-10 Codes

Visit 1: Because the pediatrician can determine the child is experiencing gastroenteritis but not the cause, you’ll first report K52.9 (Noninfective gastroenteritis and colitis, unspecified).

Based on what’s written in this case, you will report the following symptoms codes:

• R11.2 (Nausea with vomiting, unspecified)
• R19.7 (Diarrhea, unspecified)
• R50.9 (Fever, unspecified)
• E86.0 (Dehydration)

Coding alert: You likely know from memory that R10.- codes describe abdominal pain, but you won’t report abdominal pain for this case. You’ll only select a code from R10.- if “a related definitive diagnosis has not been established (confirmed) by the provider,” per ICD-10 coding guideline I.C.18.a. Because the pediatrician made a diagnosis that implies stomach pain, you’ll only use an R10 code if the stomach pain is not “associated routinely with a disease process,” as guideline I.C.18.b goes on to tell you.

Remember medical necessity: The pediatrician ordered a stool test to further assess the origin of the gastroenteritis. Reporting the abovementioned symptoms will help support the medical need for this test.

Visit 2: Test results came in, so you can update the code accordingly. The pediatrician determined that Norovirus virus is the cause of the stomach condition, which codes to A08.11 (Acute gastroenteropathy due to Norwalk agent).

The diarrhea and vomiting improved, but the child still has a fever and abdominal pain. Remember that abdominal pain is assumed with the illness, which means you’ll code R50.9 with the diagnosis to account for the fever only.

Level the Encounters to Find the Correct E/M Code

Visit 1: Time spent is not clearly stated in the case study, which means you’ll need to level the evaluation and management (E/M) service using medical decision making (MDM).

Number and complexity of problems: There is one acute illness, the gastroenteritis. While it doesn’t seem “uncomplicated,” as it would have to be to assign a low level, it also isn’t clear whether it’s accompanied by systemic symptoms, which would validate a moderate level. “An acute illness with systemic symptoms is defined as an illness that causes systemic symptoms and has a high risk of morbidity without treatment,” says Donna Walaszek, CCS-P, billing manager, credentialing/ coding specialist for Northampton Area Pediatrics LLP in Northampton, Massachusetts. The notes don’t say anything about this being high risk, so without more information, assessing this category isn’t possible. “To provide solid support for representing a problem as moderate level, the encounter note should explicitly state why,” explains Jan Blanchard, CPC, CPEDC, CPMA, pediatric solutions consultant at Physician’s Computer Company in Winooski, Vermont. MDM will likely depend on how the other two categories level.

Data to be reviewed: The pediatrician ordered one test, and a detailed history was provided by the parent, who can be considered an independent historian. That equals a moderate level for the amount and/or complexity of data to be reviewed category. Remember, you can only count the test if you’re not reporting it separately with a CPT® code.

Risk of Complications: If left untreated, the child’s fever, dehydration, and lethargy could conceivably lead to bigger health problems, and the pediatrician prescribed the medication, which indicates a moderate risk of complications.

Even though we can’t accurately assess the first MDM element, the other two level easily as moderate, so since all we need is two out of three, code this encounter as 99204/99214 (Office or other outpatient visit for the evaluation and management of a/n new/established patient… moderate level…).

Visit 2: To accurately level the follow-up visit, consider the following:

Number and complexity of problems: The pediatrician made a more definitive diagnosis, however, the virus is running its course and the symptoms are improving. This puts this category at a low level.

Data to be reviewed: The pediatrician ordered one test at the last visit, and review of that test was included during that visit, which means there is nothing to justify this level, which translates to a straightforward level.

Risk of Complications: The origin is viral and the child’s condition is already improving, but “the risk under consideration for leveling is not that of the condition itself, but of the diagnostic and treatment options considered,” says Blanchard. The OTC fever reducer, increased fluid intake and hand-washing advice present low risk, and therefore supports a low level.

Because two out of the three MDM elements meet or exceed a low level, you would code this encounter as 99213 (Office or other outpatient visit for the evaluation and management of an established patient… low level of medical decision making…).