Pediatric Coding Alert

Coding for possible and obvious trauma cases can be easy if you know what to look for

There's a simple rule of thumb when reporting child abuse exams: They generally require mid- to high-level E/M visits and use ICD-9 codes that reflect an observation, injury, sign, symptom or abuse.

Often, the first question is: What is child abuse? It's "any recent act or failure to act on the part of the parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation," says Jeffrey Linzer Sr., MD, FAAP, MICP, EMS coordinator for the emergency pediatric group at Children's Healthcare of Atlanta at Egleston during the "Child Abuse Reporting Do's and Don'ts" teleconference produced by The Coding Institute. Abuse can include "an act or failure to act which presents an imminent risk of serious harm," he adds.

Sometimes the abuse is obvious, while at others, a parent may suspect abuse but none is found. Handling these difficult situations can prove emotionally challenging without having to worry about reporting the services properly.

Generally, the amount of documentation and medical decision-making during office visits for suspected child abuse will rise to level four or five (for example, CPT 99214 , Office or other outpatient visit for the evaluation and management of an established patient ...), Linzer says. The pediatrician often performs a detailed or comprehensive examination and takes an extensive history. And he has to consider both the child's physical and mental well-being during any medical decision-making.

For example, a father brings his 11-month-old daughter into the office because she is limping. He explains that "the baby was just starting to pull herself up to stand, but now she won't crawl." After performing a detailed physical exam, ordering x-rays and reviewing a detailed patient history with the father, the pediatrician finds a femur fracture (821.xx, Fracture of other and unspecified parts of femur ...). In this case, you would probably report 99214 based on the level of care provided.

With no history of previous trauma, the physician becomes suspicious that this may be child abuse. Consequently, additional ICD-9 codes other than 821.xx will depend on the doctor's findings and expertise with the child's injuries and abuse. If the pediatrician definitely thinks that abuse occurred after a thorough investigation, you should report 995.54 (Child physical abuse) and add 821.xx to indicate the specific injury.

Keep in mind: Whether you confirm or only suspect the abuse, state law requires you to make a report to the designated authorities. Even in the case of suspected abuse, you are not making an accusation when filing the report. Although you may know that an injury is caused by abuse, you may not necessarily know who is responsible. In these situations, the authorities will determine who is responsible. The information the physician provides through the history, exam and interpretation of findings, however, will serve as a major guide in the investigation.

Labeling the parent: Nonetheless, remember that reporting a child-abuse code brands the parents. The code will launch an investigation, during which a social worker will visit the child's house and may remove the child. But if the pediatrician knows that the child was abused, she must report the incident.

Because office visits for suspected child abuse can take significantly longer than a normal E/M service because of counseling and coordination of care, keep in mind that time may be the determining factor. "When counseling and/or coordination of care dominates (more than 50 percent) the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility), then time may be considered the key or controlling factor to qualify for a particular level of E/M services," according to CPT.

For example: The pediatrician spends 20 minutes of the office visit conducting the examination and history, and then devotes 40 minutes to counseling the established patient; you can report 99215.

You may even be able to use prolonged services codes (99354-99357) if the visit is particularly protracted. For instance, if the visit lasts one hour and 10 minutes for an established patient, you would report 99215 (for the first 40 minutes) and +99354 (Prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service ...; first hour ...) to represent the additional 30 minutes.

Remember: "You must see the patient for at least 30 additional minutes to report 99354 for the first hour of prolonged services," says Richard H. Tuck, MD, FAAP, pediatrician at Primecare of Southeastern Ohio in Zanesville.

In cases of alleged sexual abuse, the pediatrician may have to perform a colposcopic examination. For example, a 12-year-old girl claims her stepfather raped her. A colposcopic gynecological exam shows clear signs of sexual assault.

Based on an external examination, you'll probably report a level-five office visit. You should also report 99170 (Anogenital examination with colposcopic magnification in childhood for suspected trauma), Linzer says. Some payers may require you to append the E/M code with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to indicate that the E/M was a significant and separately identifiable service from the colposcopy.

No colposcopy? Most pediatricians, however, don't have the large-magnification equipment necessary to perform colposcopy in the office. Consequently, they may refer such patients to an emergency department, a rape and trauma center, or an ob-gyn for the colposcopic examination.

When the pediatrician confirms abuse, you should link the appropriate ICD-9 code, Linzer says. He points to the following diagnosis list: