Pediatric Coding Alert

Grab your answers and see if you can call yourself an expert.

Answer 1:
"This would depend on the medical decision making of the provider," says Chelle Johnson, CPMA, CPC, CPCO, CPPM, CEMC, AAPC Fellow, billing/credentialing/auditing/coding coordinator at County of Stanislaus Health Services Agency in Modesto, California. "If your pediatrician found that the patient had an infection of the middle ear accompanied by a buildup of fluid," Johnson elaborates, "then you would code H66.001 [Acute suppurative otitis media without spontaneous rupture of ear drum, right ear]."

However, Donelle Holle, RN, President of Peds Coding Inc., and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana, notes that "if no otitis is found, then the H92.01 (Otalgia, right ear) will be the correct diagnosis code." "Without a specific definition of infection," Johnson concurs, "the coder would select otalgia."

Answer 2:
"Unspecified codes," Johnson reminds coders, "are assigned when neither the diagnostic statement nor the documentation provides enough information to assign a more specific code." "Other" codes are used when the diagnosis is specific but does not fit into any of the other categories provided by ICD-10.

In this case, the pediatrician has enough information to provide a specific diagnosis, so Johnson argues J01.80 would be the most appropriate in this scenario. But, Holle cautions, "coders cannot assume to determine a diagnosis code" and should solicit the provider for "feedback about using a more specific code" when necessary.

Answer 3: 
Due to the extent of the procedure, you would code 30903 (Control nasal hemorrhage, anterior, complex (extensive cautery and/or packing) any method). Additionally, Holle notes, the procedure "does not stipulate unilateral or bilateral," so, per CPT^® instructions, you would append modifier 50 (Bilateral Procedure) to indicate that the pediatrician performed the procedure on both nostrils. However, you should check with your payer first to make sure this is the preferred modifier, as some payers may want you to report LT (Left side) and RT (Right side) in these circumstances.

Answer 4:  
In this example, along with the 99381/99391 (... comprehensive preventive medicine evaluation/reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures ... infant (age younger than 1 year)) visit, you would also document for the hearing test.

Given the patient's age, you may have to use something other than a pure tone test for the hearing screen. One possibility, recommended by the American Academy of Pediatrics (AAP) in such circumstances, is 92567 (Tympanometry (impedance testing)) (Source: https://www.aap.org/en-us/documents/coding_factsheet_brightfuturespreventivemedicine.pdf), though your payer may allow other tests in this situation.

Holle notes that "documenting the hearing screen should indicate that both ears were tested and what were the results of the testing. More than likely the staff will be doing the screening," Holle continues, "so the provider should document the results of the screening in their preventive care note to show that they actually reviewed the results."

Answer 5: In this situation, you should document the patient's signs and symptoms, such as R51 (Headache), R11 (Nausea and vomiting), and R50.9 (Fever, unspecified). This, Holle suggests, and the fact that "the pediatrician will counsel the parents/caregiver on why the child has the fever, headache, and vomiting could justify a higher level of care such as 99214 [Office or other outpatient visit for the evaluation and management of an established patient ...]."

If your pediatrician also indicated that the patient had been exposed to strep, you would code Z20.818 (Contact with and (suspected) exposure to other bacterial communicable diseases) in addition to provide even more justification for ordering the strep test. More than likely, as Johnson points out, 87880 (Infectious agent antigen detection by immunoassay with direct optical observation; Streptococcus, group A) "would be used to code the rapid strep test if performed in the office."