Pediatric Coding Alert

Hint: Knowing your encounter code options and ICD-10 guidelines pays.

The scenario is all too familiar in pediatric practices across the country. A parent brings in a child who is fussy and tearful. Your pediatrician examines the child and finds nothing wrong.

How do you code such an encounter? We reached out to two coding experts to find out how they would deal with two similar, so-called “worried well” or “feared well” scenarios.

Know the Difference between Z03.89 and Z71.1

First, it’s useful to know the difference between two similar codes that might come into play when you code these types of encounters:

• Z03.89 — Encounter for observation for other suspected diseases and conditions ruled out
• Z71.1 — Person with feared health complaint in whom no diagnosis is made.

Coding alert: Even though “worried well” is a synonym for Z71.1, you should not automatically default to the code when there is nothing wrong with the patient. And even though the two codes can be used in circumstances when the patient does not receive a definitive diagnosis, there are some subtle differences between them.

“The main difference between these two encounter codes comes down to the following: Z71.1 is for a patient where no signs or symptoms have been observed, demonstrated, or suspected,” explains Chelle Johnson, CPMA, CPC, CPCO, CPPM, CEMC, AAPC Fellow, billing/credentialing/auditing/coding coordinator at County of Stanislaus Health Services Agency in Modesto, California.

Code Z03.89, on the other hand, “is for a patient with a suspected condition. It is commonly assigned based on a behavior or trait, not necessarily a sign or symptom, as you would code to the sign or symptom if it were present,” Johnson continues.

Another Way of Looking: Is This Counseling or Further Study?

If you examine the ICD-10 taxonomy, you’ll see another set of important differences between the codes.

You would use the Z03 codes when “when a person without a diagnosis is suspected of having an abnormal condition, without signs or symptoms, which requires study — but after examination and observation, is ruled out,” according to ICD-10. This means the code is more appropriate for situations when there is reason to suspect the child may have a condition, but the provider needs to wait to make a definitive determination on the patient’s condition.

The Z71 codes, however, are used for “Persons encountering health services for other counseling and medical advice, not elsewhere classified.” This means your use of Z71.1 implies that the care was more to reassure the parent and reduce caregiver anxiety.

In order to further understand the difference between the two encounter codes, consider the following two scenarios.

Scenario 1: A mother brings her child who recently got over a cold because she wants to make sure everything is OK. The provider finds no signs, symptoms, or problems.

In this situation, Z71.1 would be the correct code to use “as there are no observed, demonstrated or suspected conditions,” according to Johnson. Coding this way implies that your provider has used the encounter to reassure the caregiver that nothing is wrong or, in certain extreme circumstances, to counsel the parent in effective ways to ensure the child’s health.

Scenario 2: The mother brings in an infant saying that the baby has been pulling at the ears. On exam, the child has no fever and the ears look fine. The child is well, but the provider needs to spend extra effort to determine this.

This scenario is a little trickier to report. However, “in this case the child was presenting with a behavior that required the condition to be ruled out, so you could code Z03.89,” says Johnson.

Exception 1: If, during the examination, your provider does uncover signs or symptoms, more ICD-10 guidelines come into play. Per ICD-10-CM guideline I.C.18.a, “when a patient presents with symptoms, but after examination does not have a definitive diagnosis, a code within Chapter 18 Symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99) may be used.”

In this case, “You could also use ‘symptom-like’ diagnoses from other chapters in ICD-10,” suggests JoAnne M. Wolf, RHIT, CPC, CEMC, AAPC Fellow, coding manager at Children’s Health Network in Minneapolis, Minnesota. “In this example, if a non-communicative child was pulling at both ears, you could use H92.03 [Otalgia (ear pain), bilateral],” Wolf suggests.

Exception 2: Again, if during the examination, your provider decides that the patient’s condition warrants further observation, a different set of encounter codes would come into play. Per the chapter-specific ICD-10 guidelines (I.C.21.c.8), you would use a follow-up code.

“If the patient needs continuing surveillance following completed treatment of a disease and the condition has been fully treated and no longer exists, the follow-up code should be sequenced first, followed by the history code,” says Wolf. So, for this scenario, you would report:

• Z09 — Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm
• Z87.09 — Personal history of other diseases of the respiratory system.  

And don’t forget: “You should report the evaluation and management [E/M] code based on the amount of work performed and documented. In pediatrics, a noncommunicative child with vague symptoms often requires more of a history and exam to determine what is wrong with the patient,” Wolf advises.