Pediatric Coding Alert

Tip: Skip presenting complaints in outpatient setting if diagnosis is clear.

Your CPT codes should always be linked to an appropriate ICD-9 code, but selecting the appropriate ICD-9 code for presenting problems versus underlying conditions can be challenging. Boost your ICD-9 coding skills with this fourstep guide.

Step 1: Rely on Current Problem for Diagnostics

Establishing whether the patient is symptomatic is an important distinction to make when coding.

When the pediatrician orders testing on a patient to rule out or confirm a suspected diagnosis because the patient has some sign or symptom, he is performing a diagnostic examination, not a screening, explains Bruce Rappoport, MD, CPC, CHCC, medical director of Broward Health's Best Choice Plus and Total Claims Administration in Fort Lauderdale, Fla. In these cases, code the sign or symptom to explain the reason for the test.

Sequence: If the patient receives only diagnostic services during the visit, list the diagnosis, condition, problem, or other reason for the visit on the claim form first, instructs the ICD-9-- CM Official Guidelines for Coding and Reporting, Oct. 2009, www.cdc.gov/nchs/data/icd9/icdguide09.pdf. This code should be the chief focus of the provider's services on that day. Then, code for other diagnoses (such as chronic conditions) on the following lines.

Example 1: The pediatrician sees a premature infant while in the hospital because of suspected jaundice. You'll list 774.6 (Unspecified fetal and neonatal jaundice) as the first diagnosis. Prematurity becomes the chronic condition in this case, so file 765.1x (Other preterm infants) as the secondary diagnosis on a subsequent line.

Do not code the chronic condition if it is unrelated to the primary reason for the visit, says Becky Zellmer, CPC, MBS, CBCS, operations supervisor for SVA Healthcare Services in Madison, Wis.

Example 2: A diabetic patient presents with a rash the pediatrician diagnoses as a contact dermatitis (692.9, Contact dermatitis and other eczema; unspecified cause). Because the diabetes is unrelated to the presenting problem, include only the contact dermatitis on the claim form ��" not the diabetes. If a separate discussion related to the patient's diabetes comes up during the visit, however, you would also code for the diabetes (250.xx).

Therapy: The same coding sequence applies to patients receiving only therapeutic services during an encounter. Code first for the diagnosis or condition documented in the medical record as the chief reason for the visit, and then code for other diagnoses, including chronic conditions, as additional diagnoses.

Example 3: A premature infant receives an RSV immune globulin injection. List V04.82 (Respiratory syncytial virus [RSV]) as the first diagnosis on the claim, then 765.10 for prematurity.

Step 2: Match Coding to Final Diagnosis

The presenting symptoms may not be relevant if the pediatrician interpreted a diagnostic test before coding for the encounter.

"For outpatient encounters for diagnostic tests that have been interpreted by a physician, and the final report is available at the time of coding, code any confirmed or definitive diagnosis(es) documented in the interpretation.

Do not code related signs and symptoms as additional diagnoses," states the ICD-9-CM Official Guidelines for Coding and Reporting.

Example: A father brings his toddler to your office because of ear pain and the pediatrician diagnoses earache with acute otitis media. The earache is considered inherent to the primary diagnosis, so you report only 382.00 (Acute suppuratiave otitis media without spontaneous rupture of ear drum).

If the final diagnostic report is not available at the time of coding, simply proceed with coding signs and symptoms.

Step 3: Check Three Areas for Pre-Op Exams

If the physician performs a pre-op evaluation for a patient, don't code the reason for surgery as the primary diagnosis.

Sequence: If the chief reason for the encounter is a pre-op evaluation, list first a code from category V72.8x (Other Specified Examinations) to describe the pre-op evaluation. Then, assign a code for the condition prompting the surgery as an additional diagnosis. Code also any findings related to the pre-op evaluation.

Example: A patient who is scheduled for anesthesia for dental caries presents for a pre-op evaluation. Report V72.83 (Other specified preoperative examination) first on the claim form. As an additional diagnosis, list the appropriate ICD-9 code for the condition prompting surgery (521.00, Dental caries, unspecified) and underlying medical conditions (for instance, 493.xx, Asthma).

Alternative: If the payer won't honor this coding sequence, the American Academy of Pediatrics states you can list the condition requiring surgery first, then the V code representing the pre-op evaluation. You should technically list the V code first, but some payer systems reject claims that begin with V codes. As the third part of the diagnosis, code for any findings related to the pre-op evaluation, such as active wheezing related to the patient's asthma (493.02, Extrinsic asthma; with [acute] exacerbation).

Step 4: Select 'V' Codes for Screenings

When the patient has no signs or symptoms and you perform a test solely for screening purposes, sail past typical diagnosis codes and locate an applicable "V" code to describe the test to the payer.

Sequence: List the screening code first if the reason for the visit is specifically the screening exam, states the ICD-9-CM Official Guidelines for Coding and Reporting. Report the screening code as an additional code, however, if the provider performs the screening during an office visit for other health problems.

For example, the pediatrician screens a patient for hyperlipidemia and hypercholesterolemia. Include V77.91 (Screening for lipoid disorders) on your claim.

Add on: If the screening returns an abnormal result, then code those results as an additional diagnosis.