Pediatric Coding Alert

Test your coding skills against our answers with this quick quiz.

Many of the illnesses that your pediatric practice sees each day have to do with the ear, nose and throat—but do you know how to code these situations? Read the following five questions and determine how you’d report these services before you check out our expert answers.

Check These Quiz Questions

Question 1: A father brings his toddler to your office because of ear pain and the pediatrician diagnoses an earache with acute otitis media. Should you report the ICD-9 code for otalgia, or the one for otitis media?

Question 2: The pediatrician diagnoses the patient with fungal sinusitis. Which diagnosis codes apply to this condition?

Question 3: An established patient reports to the pediatrician after a ball hit her in the face during a soccer match. Her nose is bleeding, and her right eye is blackened. The physician is not able to stop the bleeding with ice or pressure, so she performs repeated and extensive cautery using a silver nitrate stick on both nostrils. The bleeding relents, and the physician orders an x-ray to ensure that the patient’s nose is not broken. Results are negative. Notes indicate a level-four E/M. Can you report 30903 x 2, since the physician stopped bleeding in both nostrils?

Question 4: Can we separately report hearing and vision screenings during preventive visits, or should we bundle those into the well child visit code?

Question 5: Which diagnosis codes should you report for a strep test that comes out negative if the patient didn’t have pharyngitis, scarlet fever, or tonsillitis, and you only performed the test because the patient had vomiting, rash, and headache?

Check Your Responses Against These Answers

Answer 1: The earache is considered inherent to the primary diagnosis. Therefore, you should report only 382.00 (Acute suppurative otitis media without spontaneous rupture of eardrum).

“For outpatient encounters for diagnostic tests that have been interpreted by a physician, and the final report is available at the time of coding, code any confirmed or definitive diagnosis(es) documented in the interpretation. Do not code related signs and symptoms as additional diagnoses,” states the ICD-9-CM Official Guidelines for Coding and Reporting.

If, however, the physician does not find any other condition besides ear pain, he should code the ear pain diagnosis code instead (such as 388.70, Otalgia unspecified).

Answer 2: Although looking up “Sinusitis: due to: fungus, any sinus” in the Alphabet Index, Volume 2 of ICD-9-CM directs you to “117.9,” a single code doesn’t describe fungal sinusitis. You should instead use a combination of ICD-9 codes to represent the condition.

“Use additional code to identify manifestation,” according to the initial instruction for category 110-118, Mycoses. For the primary diagnosis, list the chronic or acute sinusitis. Then code the underlying fungal infection as the secondary diagnosis. Here’s how:

Step 1: Report the appropriate sinusitis code for sinus membrane lining inflammation. Use 461.x for acute sinusitis. For chronic sinusitis -- frequent or persistent infections lasting more than three months -- assign 473.x. Choose the fourth digit code based on where the sinusitis occurs. For example, for ethmoidal chronic sinusitis, you should report (473.2, Chronic ethmoidal sinusitis). Your pediatrician will most likely prescribe a decongestant, pain reliever or antibiotics to treat sinusitis.

Step 2: Assign the ICD-9 code that represents the fungal infection. Category 117 lists several types of mycoses that offer a more specific diagnosis than 117.9 (Other and unspecified mycoses). For instance, suppose a patient has chronic ethmoidal sinusitis due to aspergillosis (117.3), an infection that can affect the sinuses and is caused by inhaling the fungus aspergillus, which is found in compost heaps, air vents and airborne dust.

Enter 473.2 as your primary diagnosis and 117.3 as your second diagnosis.

Answer 3: No, you’ll report this service under the bilateral procedure guidelines. On the claim, report the following codes:

• 30903 (Control nasal hemorrhage, anterior, complex [extensive cautery and/or packing] any method) for the repair
• Modifier 50 (Bilateral procedure) appended to 30903 to show that the physician treated both nostrils
• 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history; a detailed examination; and medical decision making of moderate complexity ...) for the E/M
• Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) appended to 99214 to show that the E/M and repair were separate services.

You’ll also report several diagnoses:

• 784.7 (Epistaxis) appended to 30903
• 920 (Contusion of face, scalp, and neck except eye[s]) appended to 99214
• E917.0 (Striking against or struck accidentally by objects or persons; in sports without subsequent fall) appended to 30903 and 99214 to represent the cause of the patient’s nosebleed 
• E007.5 (Activities involving other sports and athletics played as a team or group; soccer) appended to 30903 and 99214 to represent the circumstances surrounding the patient’s nosebleed.

Note: Although including E codes on your claim is optional, they provide a more complete picture of the circumstances surrounding injury. ICD-9 2010 greatly expanded your E code choices so that you can better explain many situations.

Answer 4: Bright Futures guidelines support various types of screenings along with preventive medicine visits, which typically include vision, hearing, and developmental testing. You should separately collect from most payers for all of these screenings. 

For example: You perform a preventive medicine visit on a nine-month-old patient, and also perform standardized developmental testing on the infant. You’ll report 96110 (Developmental screening, with interpretation and report, per standardized instrument form with the preventive medicine code. Append modifier 25 to the preventive medicine service code.

Likewise, if you perform a hearing screening on an older child, you’ll report the appropriate code, such as 92551 (Screening test, pure tone, air only). For vision screening, you’ll report 99173 (Screening test of visual acuity, quantitative, bilateral). In most cases, you’ll have to append modifier 25 to the preventive visit code when billed with these services. 

Answer 5: If questioned, the physician should write a letter appealing the claim and noting that based on his clinical diagnosis, the patient exhibited other symptoms of strep besides pharyngitis and scarlet fever. For instance, the combination of headache (784.0), abdominal pain (789.00), and vomiting (787.03) led the physician to believe that the patient may have been experiencing strep throat. If the patient mentioned exposure to strep at school or at home, the physician should mention that in his letter, and you should report the appropriate V code for it (for instance, V01.89, Contact with or exposure to other communicable diseases).