Pediatric Coding Alert

You're going to have to use an extra V code to separate routine lead screenings from exposure testings. See if you can navigate the nuances of ICD-9 coding for possible lead poisoning with this case study.

The case: A hospital's adoption clinic routinely uses a lead poisoning diagnosis (984.9) on all patients to justify blood testing for lead. Is it appropriate for the clinic to use the poisoning code?

No, says Jeffrey F. Linzer Sr., MD, MICP, FAAP, FACEP, associate medical director of compliance and business affairs for the division of pediatric emergency medicine Department of Pediatrics at Children's Healthcare of Atlanta at Egleston. "Billing for a condition that doesn't exist is fraud." Using the lead poisoning (984.9) diagnosis just to get paid for a test, especially if the patient is without symptoms and the screen is normal, is inappropriate. Linzer suggests that the clinic use this set of codes:

• V70.3 -- Other medical examination for administrative purposes (adoption)

• V15.86 -- Exposure to lead

• V82.5 -- Special screening for chemical poisoning and other contamination.

You should use the lead poisoning diagnosis only when a person has that condition. To enter 984.9, Linzer says, the physician must either:

• "determine the patient has findings [or symptoms] consistent with the poisoning" or

• interpret a lab test "as being consistent with poisoning or toxicity," meaning the test came back positive for high lead levels.

There's even a middle-of-the-road code you can use for elevated lead levels. When a child is asymptomatic for lead poisoning and the test results are positive for elevated levels of lead, you would report 790.6 (Other abnormal blood chemistry), Linzer says.

For the E/M encounter in which the pediatricians order the lead screening, you're going to use at least two V codes -- one for the service and one for the screening test.

Easy: You'll always use the same diagnosis for the lead screening. Report V82.5 (Special screening for chemical poisoning and other contamination) when you test for lead contamination.

Choose the service V code based on whether the pediatrician performed a preventive medicine service or an adoption exam. "At a well-child exam in which the pediatrician tests the 12-month-old for lead without a history of exposure, you would report V82.5 and V20.2 (Routine infant or child health check)," Linzer says. For an adoption exam (any age) that involves lead testing, use V70.3 and V82.5.

Reality: Some plans will not pay for a routine lead screening's associated blood collection (36415 or 36416) or lab test (83655, Lead). One pediatric practice received lead screening test kits done by fingerstick that the manufacturer claimed insurers would pay $10 for each test completed. "When I billed the insurance companies for the test, payment was denied," says Lynn Anzuini, RN, office manager at Harry Modestin's office in Trenton, N.J. When she resubmitted for the blood draw, the insurers again denied the claims.

Insurers might deny lead screening due to preventive services' noncoverage. For instance, "Aetna considers lead screening a medically necessary preventive healthcare service for children," states the insurer's Clinical Policy Bulletin: Lead Testing. But because some Aetna plans exclude coverage of preventive services, routine testing may be a noncovered service, the policy says.

If the patient has a history of lead exposure, add V15.86 (Exposure to lead), Linzer says. "Report the exposure code at the time of the visit if there is a suspicion or confirmed exposure."

Example: A pediatrician orders lead screening because the patient is an international adoptee from China, where lead poisoning is prevalent. Because of the known risk, the physician could use V15.86, Linzer says.

Code V15.86 might be the path to payment for lead screening. The Centers for Disease Control and Prevention, the U.S. Preventive Services Task Force, the American Academy of Pediatrics, and the American Academy of Neurology recommend lead screening of preschool-age children in certain high-risk groups. These include children who:

• have emigrated (or have been adopted) from countries where lead poisoning is prevalent

• are developmentally delayed.

Following these recommendations, Aetna covers lead screening reported with either a developmental delay diagnosis or a lead exposure diagnosis.

Action: If an insurer balks at paying for lead screening with a V15.86 diagnosis, contact your insurance representative and stress that you are doing these screens for adopted children from countries with known high levels of lead. Point out that the AAP's statement on lead exposure supports the screening's medical necessity. Many case reports show that children who are recent immigrants, refugees or international adoptees have elevated (sometimes very elevated) blood lead concentrations. "Such children should be screened on arrival in the United States," the policy says.

The AAP's policy advocates that the U.S. government "require coverage of lead testing for at-risk children by all third-party payers by statute or regulation." Download the policy from http://aappolicy.aappublications.org/cgi/reprint/pediatrics;116/4/1036.pdf.

Feel free to also code any abnormal findings in addition to the V codes. "The physician can always code for abnormal findings that contribute to the reason for the encounter," Linzer says.

Example: An international adoptee from a country where lead poisoning is prevalent also shows signs of development delay. The test comes back negative.

Do this: You code the abnormal finding with 315.00-315.9 (Specific delays in development), the lead screening with V82.5, and the lead exposure with V15.86. Because you have abnormal clinical findings, use V82.5 and V15.86 as secondary diagnoses.