Pediatric Coding Alert

The common complaint of abdominal pain can result in many potential diagnoses, and may lead to a hospital observation stay or even surgery. The following case study examines three coding scenarios related to abdominal pain and how to code each successfully.

Scenario 1: Office Visit Only

An established, 13-year-old female patient arrives at the pediatricians office. She has had midabdominal pain for 12 hours, with one episode of vomiting during that time. There is no diarrhea, fever or dysuria, and her last menstrual period occurred two weeks ago. On physical examination the patient appears well-hydrated with moderate abdominal pain on deep palpation, but no rebound tenderness. The results of a urinalysis (81000, urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, with microscopy) are normal. The physician arrives at a differential diagnosis of gastroenteritis, midcycle ovulatory pain, mesenteric adenitis or a developing surgical abdominal problem such as early appendicitis.

This office visit is CPT 99213 , says Richard H. Tuck, MD, FAAP, a member of the American Academy of Pediatrics Coding and Reimbursement Committee and a practicing pediatrician in Zanesville, Ohio. The history is expanded problem-focused, with a problem-pertinent system review, and the examination is expanded problem-focused with a limited examination of the affected body area and other related organ systems. Medical decision-making qualifies as moderately complex there are multiple diagnoses, a moderate amount of data and a moderate risk of complications. Potential gynecological concerns complicate the medical decision-making, Tuck explains. You also need information about the family history of gastrointestinal problems.

The office visit should be linked to diagnosis code 789.07 (abdominal pain, generalized).

The level of the visit may rise to 99214 if a detailed history including a past, family or social history of the gastrointestinal problem as well as an extended history of the problem and a review of additional systems beyond the gastrointestinal system, are medically necessary and properly documented. Similarly, if the child exhibits a coincidental respiratory illness with cough or fever (pneumonia can mimic appendicitis), the visit might qualify as a 99214, says Tuck. A detailed examination (involving another related organ system) might also raise the level of evaluation and management (E/M).

If the pediatrician performs an x-ray in the office as part of the examination, code 74000 (radiologic examination, abdomen; single anteroposterior view) in addition to the E/M service.

Scenario 2: Observation

Later that evening the patients condition worsens, and the pediatrician meets her at the hospital emergency department.

The abdominal pain has moved to the right lower quadrant, and the patient is experiencing persistent nausea and vomiting, has had one loose stool and her temperature has risen to 101. The pediatrician [...]