Pediatric Coding Alert

Remember that Z00.129 isn’t your only well-visit option.

Pediatric practices are all too familiar with this scenario: A worried parent, especially the new one, who wants to bring the baby in just to make sure everything is okay. Maybe it’s a six-month-old whose mother thinks is teething, or perhaps it’s a one-year-old who is cranky and maybe he has an ear infection that they’d like you to simply check. Even older kids come in with potential sprains or fractures, but you see the child, and in fact, nothing is wrong. How do you bill for these visits?

The answer is to bill for the symptoms, since you can’t bill for parental anxiety, and in some cases reporting the appropriate “Z” code.

Worried Well Coding

One diagnosis code that could be appropriate for these cases is Z03.89 (Encounter for observation for other suspected disease and condition, ruled out), particularly for those instances when a parent fears the patient has a problem but the visit results in no diagnosis.

Here’s where it applies: A mother brings her child who recently got over a cold to the pediatrician prior to a cross country trip to see grandmother, “Just because I want to make sure everything is OK and the cold is gone,” the mother tells you. There are no signs, symptoms or problems other than the fact that the mother wanted to ensure that the cold is gone. This is a perfect place to use Z03.89 all by itself because there is no other problem present. The parent may have to pay for this visit as insurance will often (but not always) deny payment for this diagnosis code. Here, no specific feared condition is present, making Z03.89 your best bet.

Here’s where you may not need it: 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 you need to spend extra effort to determine this, warranting an E/M code such as 99213 (Office or other outpatient visit for the evaluation and management of an established patient…). To support the E/M code, you should use otalgia (the affected ear was not specified, so the code would be H92.09) as the primary diagnosis. In this situation, you don’t need a Z code.

It is very important to push to find out what the parents are worried about. Get them to be as specific as possible about the illness they are afraid the child has so you can code the symptoms if necessary, as in the case of the otalgia case above.

Many pediatricians attribute non-specific crying in very young infants to colic (R10.83). They use the diagnosis code for the symptom as the primary diagnosis, followed by Z03.89, which is for ruling out a specified suspected condition, to show that the diagnosis actually is not present. Fortunately, pediatricians don’t typically have a hard time getting reimbursed for these visits in newborns.

Coding Tips: In ICD-10 2017, there are new Z codes for observation and evaluation for the newborn, condition ruled out, perfect to use for that three to five day-old visit where the neonate is being evaluated for weight loss, jaundice, or possible cardiac issue.

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