Pediatric Coding Alert

Certain V codes describe an encounter but may not be payable when used alone. But they can be combined with other diagnosis codes to give a clear picture of the overall diagnosis, including the original complaint. The combination makes the claim payable as well as accurate. This is a controversial topic, with coding experts differing on the interpretation of how to use ICD9 Codes.

Use V71.x Instead of V65.5

The "worried well" diagnosis V65.5 (Person with feared complaint in whom no diagnosis was made) at first may seem appropriate for pediatrics, where the patient frequently cannot communicate verbally and the parents and pediatrician want to make sure the child is not ill. But using this diagnosis code most often results in denial. Insurance companies generally do not want to pay for a pediatrician to reassure a young mother that her infant's spitting up is normal or for a pediatrician to look in the ears of a preschooler before a family vacation merely to rule out an ear infection in the absence of any signs or symptoms. If you use V65.5 with these visits, the payer probably will deny the claim, and you will have to write it off or bill the parents. How should you handle the "worried well"?

Use V71.x (Observation and evaluation for suspected conditions not found) instead, recommends Jeffrey Linzer Sr., MD, American Academy of Pediatrics (AAP) representative to the ICD-9 editorial advisory board, AAP Coding and Reimbursement Committee liaison, professor of pediatrics at Emory University, and director of emergency medicine at Children's Healthcare of Atlanta and Hughes Spalding Children's Hospital. The V71.x series of codes shows that the pediatrician was looking for a problem but did not find it.

"If you perform an examination looking for a medical condition but don't find one, use the appropriate V71 observation code instead," Linzer says. In the example of the child with recurrent ear infections but no current symptoms, use V71.89 (Observation and evaluation for suspected conditions not found; other specified suspected conditions), he says.

The otitis media example is a common dilemma for pediatricians and can be solved by some judicious questioning of the parents. If there are truly no symptoms and the parent merely wants the pediatrician to check the child's ears before a weeklong road trip, you should use V71.89. There may be a complaint that can be coded instead, however, such as ear pain (388.7x, Otalgia) or a recent cold (487.1, Influenza; with other respiratory manifestations).

If a "worried well" condition exists in a newborn (28 days or fewer), use V29.x (Observation and evaluation of newborns and infants for suspected condition not found). For example, a mother of a 2-week-old comes in because she is concerned about spitting up she thinks the baby is vomiting. You should report 779.3 (Other and ill-defined conditions originating in the perinatal period; feeding problems in newborn) the complaint first and V29.8 (Observation and evaluation of newborns and infants for suspected condition not found; observation for other specified suspected condition) the diagnosis second. This combination tells the payer that the pediatrician looked for and did not find the condition. It also shows the payer that the complaint indicated a possible feeding problem.

In another example, a pediatrician admits a neonate with fever (780.6) to the hospital. The infection workup is negative. The discharge diagnoses should be 780.6 and V29.0 (Observation and evaluation of newborns and infants for suspected condition not found; observation for suspected infectious condition), Linzer says.

When searching for an accurate diagnosis code other than V65.5, you should focus on the chief complaint, recommends Donelle Holle, RN, coding educator for the University of Michigan Health System, department of pediatrics, in Ann Arbor. For example, if the parent brings the child in because there has been a spate of meningitis reports in the state and the child has a fever (780.6), vomiting (787.01, Nausea with vomiting) and a stiff neck (781.6, Symptoms involving nervous and musculoskeletal systems; meningismus), you should report those symptoms, she says. But if there is no chief complaint, you may have no choice but V65.5, Holle says. "If the mom says the child was at the same school with a child who had meningitis, but the child has no fever, vomiting, stiff neck or symptoms of anything, then I would use V65.5," she says. And she recommends warning the parent that a bill might be forthcoming.

Linzer recommends an alternative strategy code V65.5 in the secondary position in the meningitis-scare scenario, with V71.89 as the primary diagnosis.

Preoperative Examinations

The V codes for preoperative examinations (V72.81, Pre-operative cardiovascular examination; V72.82, Preoperative respiratory examination; V72.83, Other specified pre-operative examination; and V72.84, Preoperative examination, unspecified) should be used in the secondary position with the reason for the surgery in the primary position, Holle says. The exception is when the child has a risk factor, in which case that diagnosis should be in the primary position, Holle says.

For example, a pediatrician refers a child to an otolaryn-gologist for an evaluation for ear tubes. The otolaryngologist decides the surgery is necessary and sends the child back to the pediatrician for preoperative clearance. If the child has no risk factors, you should use V72.83 first and otitis media (usually 381.10, Chronic serous otitis media, simple or unspecified; 381.20, Chronic mucoid otitis media, simple or unspecified; or 382.1, Chronic tubotympanic suppurative otitis media), the reason for the surgery, second, with the E/M code for the examination.

If you find a significant murmur in the preoperative exam, you should code the murmur because that will have an effect on the status for the anesthesiologist, Linzer says.

For example, a child with a heart murmur is to have dental surgery, and the dentist refers the patient back to the pediatrician for preoperative clearance. You should use the heart murmur (785.2, Symptoms involving cardiovascular system; undiagnosed cardiac murmurs) in the primary position, with dental caries (521.0x, Diseases of hard tissues of teeth; dental caries) second and V72.83 third, says Holle. "You should put the heart murmur up front to show why you're doing a head-to-toe exam for a dentist." An innocent functional murmur is not coded at all, Linzer adds.

Follow-up Visit

There is widespread disagreement among coders and pediatricians regarding proper diagnosis coding for rechecks. For example, when a child is treated for otitis media with antibiotics and returns 10 days later for a recheck, some coding experts say the only correct code is V67.59 (Follow-up examination; following other treatment, other). Others argue to use the diagnosis for the original condition in the primary position, with V67.59 in the secondary position, because this combination denotes a resolved condition. Another V code recommended by purists for rechecks is V67.9 ( unspecified follow-up examination). But realists point out that whether you report V67.59 or V67.9 does not matter because many insurance companies will deny the claim with either diagnosis.

"Payers vary on this," Holle says. "Medicare says that if a patient is being seen in follow-up and the problem is cleared, you should still put the problem diagnosis, like otitis media, and then follow it with V67.59." But some payers direct that V67.59 be used and then deny the claim.

Peter Rappo, MD, FAAP, who practices in Brockton, Mass., says if you have to use V67.59, use it only as a secondary diagnosis. "In an ideal world, V67.59 would be the primary diagnosis," he says. "But insurance companies can't differentiate between otitis media acute and otitis media resolved." In addition, virtually all insurance company computers reject V67.59 as a primary diagnosis, Rappo says. "We've asked the insurance companies what they want us to do, and they say they don't particularly care if they know whether the condition is resolved or not."

If the follow-up is related to a chronic condition, you can always use the chronic condition diagnosis for the recheck. For example, a patient who had an asthma attack and comes back in a week for a recheck still has asthma even if the acute attack is gone. You should code the follow-up visit 493.00 (Extrinsic asthma; without mention of status asthmaticus or acute exacerbation or unspecified). In the initial visit, the fifth digit would indicate the attack, either as 493.01 ( with status asthmaticus) or 493.02 ( with acute exacerbation).

Family History Diagnosis Codes

Certain V codes (V16.x, Family history of malignant neoplasm; V17.x, Family history of certain chronic disabling diseases; V18.x, Family history of certain other specific conditions; and V19.x, Family history of other conditions) denote a family history of a disease. For example, because of a family history of high cholesterol and heart attacks, a 5-year-old child comes in for a cholesterol check. The child is not showing any signs of high cholesterol but needs to be evaluated. "To some payers, a cholesterol check on a 5-year-old makes no sense," Holle says. "But if you use the 'family history of' V code and the claim is rejected, you can explain that the visit isn't a screening but is due to the history of the child's family."

Note: Hospital-based coders have the benefit of being able to code possible, probable and rule-out diagnoses. On the physician side, you cannot. In the hospital setting, the more diagnoses listed, the more chance for a higher diagnosis-related group (DRG). For example, a patient with fever (780.6) and nuchal rigidity (781.6) who is diagnosed with meningitis would have all of those diagnoses listed. For physicians, you would code only the definitive diagnosis 047.x (Meningitis due to enterovirus ).

Request for Evaluation

A parent occasionally brings in a child with no symptoms because another party has requested the evaluation. This happens frequently when a teacher or school nurse recommends to a parent that a child be evaluated for attention deficit hyperactivity disorder (ADHD). If there is no evidence of ADHD, you should use the diagnosis code that correlates with the behavior that prompted the request, such as 312.30 (Disturbance of conduct, not elsewhere classified; disorders of impulse control, not elsewhere classified; impulse control disorder, unspecified).