Pediatric Coding Alert

If you want to receive full reimbursement for anaphylaxis from bee stings, you have to report 989.5, 995.0 and E905.3 or risk payers thinking your pediatrician treated an allergic reaction instead.

Many pediatric coders fail to paint an accurate picture of a toxic reaction to insect venom, coding experts say. You may overlook reporting the most specific reason for the encounter and instead focus on the allergic response and/or symptoms due to an unawareness of what anaphylaxis entails.

Multiple Body Organ Involvement Points to 995.0

Thinking that allergic episodes are the same as anaphylaxis will result not only in the wrong ICD-9 code but also in the payer not understanding the severity of the encounter. Although allergic reactions are a type of anaphylaxis, allergic responses involve local or general reaction to one body system, such as the skin. In contrast, anaphylactic shock affects multiple body systems, says Jeffrey LinzerSr., MD, MICP, FAAP, the American Academy of Pediatrics'representative to the ICD-9-CM editorial advisory board.

"By definition, anaphylaxis syndrome is an explosive multisystem immune reaction," Linzer explains. Generally, skin (urticaria) and respiratory (hoarseness, cough, wheezing) symptoms first appear, but cardiac (hypotension, arrhythmias) and gastrointestinal (vomiting, bloody diarrhea) problems may develop as well, he says.

For instance, a bee stings a 12-year-old boy with a history of atopic dermatitis (691.8, Other atopic dermatitis and related conditions). Because he has generalized hives (708.0, Allergic urticaria) and suddenly starts wheezing (786.07), his father brings him to the pediatrician's office.

"This child is most likely having anaphylaxis," Linzer says. Therefore, you should report the more specific anaphylaxis diagnosis (995.0, Certain adverse effects not elsewhere classified; other anaphylactic shock) rather than the allergic reaction (995.3, Allergy, unspecified) or the symptoms (708.0, 786.07), he explains. "Because the urticaria (708.0), wheezing (786.07) and allergic reaction (995.3) are inherent in the other diagnoses (989.5, 995.0 and E905.3), you should not code them separately."

Do not allow the term "shock" to dissuade you from thinking the above scenario does not meet the criteria for 995.0. "Shock is not required to make the diagnosis," Linzer says. Instead the child needs to show signs of an immediate response to specific antigen that results in life-threatening respiratory distress, according to the ICD-9 manual.

First Identify Why the Reaction Occurs

Now that you have zoomed in on one 900 code, consider the primary reason for the encounter the bee sting. You may inadvertently overlook this reason and report 995.x only.

But, in the case of anaphylaxis due to insect bites, the venom triggers the reaction. Therefore, you should report 989.5 (Toxic effect of other substances, chiefly nonmedicinal as to source; venom) in the primary position, Linzer says.

Coding 995.3 without 989.5 would omit the reason for the shock.

E905.3 Explains the Cause

Finally, you must identify the source of the anaphylactic syndrome. Although some payers do not accept external cause codes, you should use an E code to identify what caused 995.0, according to ICD-9. The manual groups hornet, wasp and bee stings causing toxic reactions under E905.3 (Venomous animals and plants as the cause of poisoning and toxic reactions; hornets, wasps, and bees).