Pediatric Coding Alert

E/M level, testing codes, and Dx coding to seven digits are key.

A six-year old girl falls off a slide at the playground and lands on her head. A teenage athlete takes a hard hit to the helmet during football practice. Concussion is a very real problem for active kids.

It can also be a problem for coders, too, as assigning the correct codes for patient testing and for the eventual diagnosis can be tricky. So, take this advice and find relief from the headaches that surround coding this condition.

Code for E/M

"Simple concussions usually require little intervention," points out Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania. Most often, Falbo says, this means that "it is sufficient for a patient to follow up with their pediatrician," where "diagnosis and care for a concussion or a head injury begins with a pediatrician evaluating the patient's symptoms and taking a history of the condition." For a treatment plan, Falbo continues, the pediatrician would probably recommend observation, symptom management, nonparticipation in activities that could aggravate the injury, and rest.

Consequently, there is certainly enough here to justify coding a level-four evaluation and management (E/M) service for this situation. Not only do the exam and history fulfill the criteria for the detailed history and detailed examination components of 99204/99214 (Office or other outpatient visit for the evaluation and management of a new/established patient ...), but the management options and risk of complications are sufficient to provide two out of the three elements necessary to document a moderate level of medical decision making (MDM). And the additional counseling involved with the condition would easily satisfy the 25-minute time threshold for the service if you decided to code by time.

Code for Testing

To assess the patient's cognitive functions, your pediatrician may well also administer an evaluation tool to determine the severity of the patient's condition. This particular kind of test does not have a precise CPT^® code attached to it, but that shouldn't send you scurrying for a code from the central nervous system assessment/tests section of CPT^®.

Coding 96116 (Neurobehavioral status exam ...), for example, is not only inaccurate in this scenario, it could also lead to problems down the line. Per Correct Coding Initiative (CCI) edits, 96116 is a column 2 code for E/M services. So, even though it is possible to bill for the exam, the code is actually bundled into the E/M service your pediatrician is providing.

Instead, Donelle Holle, RN, President of Peds Coding Inc., and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana, recommends that if your pediatrician administers a test such as the sport concussion assessment tool (SCAT) 2 or 3, you should use 96160 (Administration of patient-focused health risk assessment instrument (eg, health hazard appraisal) with scoring and documentation, per standardized instrument).

Code for Diagnosis

The ICD-10 codes for concussion are, on the surface, easy to assign based on the patient's history. You would choose S06.0X- (Concussion), adding a sixth digit, 0, if the patient did not lose consciousness during the incident; 1 if there was a loss of consciousness that was less than 30 minutes; or 9 if a loss of consciousness of an unspecified duration occurred.

The code, however, takes a seventh digit that can muddy the waters for coders. If this is the patient's first encounter for the condition, you would add the seventh digit, A, for the initial encounter. But Holle notes that, "if the patient is seen again in a week and now has no further symptoms of the concussion, it is an office visit at the appropriate established patient level of care (99212-5). But now, for the diagnosis code, Holle reminds coders that "the seventh digit will be a D for subsequent visit because the patient is in the healing phase and no longer under treatment."

Also, Holle reminds coders, "you should add a code from chapter 20 to describe how the concussion happened." So, to code the two hypothetical situations mentioned earlier, you could use codes such as W09.0XXA (Fall on or from playground slide, initial encounter) or W21.81XA (Striking against or struck by football helmet, initial encounter) and Y92.321 (Football field as the place of occurrence of the external cause) to round out your reporting.