Pediatric Coding Alert

Chances are that few, if any, of your patients will contract meningococcal meningitis (036.0). But recent outbreaks of the fatal disease, which strikes mostly high school and college students, have sent parents into panic. Many parents in the country heard about the Ohio outbreak this past spring and were demanding more information. Pediatricians were deluged by telephone calls from frantic parents who wanted to know if they should keep their children home from school.
 
Parents want to know exactly what the disease is and how it is spread and if their children should be immunized. How can you handle these circumstances and recoup some reimbursement? And how should you handle general prevention of meningococcal meningitis?
 
One of the primary educational tasks of the pediatrician is to differentiate between meningococcal and viral meningitis (047.9, aseptic). Meningococcal is the disease that captured headlines and panicked parents. Viral meningitis is much more common and less serious. But because it is more common, your practice is likely to get many calls from parents who have read newspaper stories or seen the news on TV about meningococcal meningitis and heard about a child in their school who has viral meningitis. These parents register only the word "meningitis," so your staff will first need to ascertain what kind of meningitis the child was really exposed to.
 
Once you know the parent is referring to meningococcal meningitis, you can proceed with counseling and, if necessary, prophylaxis.

 
If a child in your community develops meningococcal meningitis, be assured that you and your staff will spend much time on the telephone discussing this with your patients' parents.
 
In such a situation, any child who has been exposed to the disease should be immunized. "This means children in the same family. It does not necessarily mean children who go to the same school should be vaccinated," says Louis Cooper, MD, FAAP, vice president of the American Academy of Pediatrics and professor of pediatrics at Columbia University in New York City.
 
Most children should not be vaccinated for meningococcal meningitis on a routine basis, because these vaccinations can limit immunity and are expensive, Cooper says.
 
Nevertheless, when they hear that a vaccine is available (CPT 90733 , meningococcal polysaccharide vaccine [any group(s)], for subcutaneous or jet injection use), these parents will almost invariably want it, whether it's necessary or not. You must explain to the parent why vaccination may not be necessary -- a possibly time-consuming process that you cannot be paid for unless you see the child.
 
Your nurse can explain the guidelines for exposure and immunization over the telephone. If the parent accepts the nurse's explanation and retreats from the request for the immunization, then the case ends there. You will not be able to bill, but your time investment is minimal. "This is a public service you may need to perform," Cooper says. "For most cases, the doctor is likely to spend a relatively short period of time on reassurance."
 
If the parent still insists on the immunization, you may need to explain why it's not justified. If you do this on the telephone, you can bill -- but probably not be paid for -- the telephone code, 99371-99373. Or you could see the parent and child in the office and explain it then, billing an E/M code based on the time spent.
 
When counseling parents whose child is healthy but who are concerned about the disease, the main coding dilemma is the diagnosis code. If the child has no symptoms and is well, some coders might choose diagnosis code V65.5 (person with feared complaint in whom no diagnosis was made). The insurance company will probably deny this code, and you will have to bill the parents, which amounts to punishing them for bringing their child to the office. Do not use diagnosis code V65.5 in this situation.
 
Do not try to evade the problem by listing the meningococcal meningitis diagnosis code first and V65.5 second for these cases. The child doesn't have meningococcal meningitis, so you cannot list that diagnosis code -- not first, not second.
 
Furthermore, this is an extremely serious disease; you do not want it in the child's insurance history if he or she didn't have it. 

Presence of Symptoms

 
The nurse's telephone explanation of immunization and meningococcal meningitis is only for the asymptomatic child with the worried parent, not for the child with symptoms. And because the symptoms of meningococcal meningitis can resemble symptoms of a cold or flu, you will get many of these calls in the wake of a meningococcal meningitis outbreak. The parent will probably bring the child in for peace of mind. You should code an office visit along with the diagnosis code for the signs and symptoms, such as pharyngitis (462) or upper respiratory infection (URI, 465.x).
 
You do not want a nurse to handle these calls merely with education, says Charles A. Scott, MD, FAAP, who practices with Medford Pediatric and Adolescent Medicine in Medford, N.J. Careful triage will help you determine whether you need to see the child, but at the height of a meningitis scare, expect to have some schedule disruptions due to extra visits.
 
Also, you will spend additional time counseling these parents on issues related to meningitis. If more than 50 percent of the encounter time is spent on counseling, code the level of service based on time.
 
Do not use the "worried well" diagnosis code (V65.5) for these cases. The child is not well -- he or she has symptoms.  

Prevention Coding
 
 
When a child is going to college or boarding school, the pediatrician gives a meningococcal meningitis vaccination (90733). Any child who will be living in a dormitory should be immunized.
 
For a child who has had significant exposure to meningococcal meningitis, prescribe two days of Rifampin, Cooper says. Bill an E/M service for the visit, with V01.8 (contact with or exposure to communicable diseases; other communicable disease) as the diagnosis code.
 
When you administer the meningococcal meningitis injection, bill 90471 (immunization administration [includes percutaneous, intradermal, subcutaneous, intramuscular and jet injections and/or intranasal or oral administration]; one vaccine [single or combination vaccine/toxoid) in addition to 90733.