Pediatric Coding Alert

Often, ‘V’ codes will be required for such visits.

Unfortunately, every pediatrician will come across suspected abuse and neglect cases at some point during their time practicing, and although the pediatrician is typically glad when abuse is not found, it can create coding challenges. Consider the following two scenarios for your abuse and neglect check coding. 

1. Parent Suspects Abuse, But None Found

For treating a possible abuse case with no findings, you may code the E/M based on time and use a diagnosis code that reflects the negative results.

A common scenario is the parent who shows up in your office on Monday morning after the child spent the weekend with the noncustodial parent. The mother says, “I just want to see if my child was abused.” The pediatrician asks the child if anyone touched him inappropriately over the weekend and if anyone hurt him. The boy answers “No” to the questions. Upon examination, the pediatrician finds no signs of abuse whatsoever.

In this situation, the level of E/M code that you select will depend on the amount of time the physician spent talking to the child and the depth of the exam. While at a minimum, you could report 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...) for an expanded problem-focused history and exam, this type of suspected abuse would likely lead to a detailed history and exam and meet the requirements for moderate-complexity medical decision-making (99214). The time the pediatrician spent counseling and coordinating care could become the key component justifying 99215, as long as the total time spent and the time spent counseling are both documented in the record.

For an exam that results in no abuse/neglect findings, you should report V71.81 (Observation and evaluation for other specified suspected conditions; abuse and neglect) as a principle diagnosis.

2. Assault Is Obvious

When the abuse case is very clear-cut, you should use the abuse codes.

For example, a 12-year-old girl is brought to your office and says that her stepfather hurt her. A gynecological exam shows clear signs of sexual assault.

Based on the external examination, you’ll probably report a level-five office visit, and you may refer the patient to the emergency department, a rape and trauma center, or an ob-gyn for further examination using colposcopy.

To report the rape, you would use 995.53 (Child sexual abuse), as well as an E code to identify the perpetrator. For rape by a stepfather, you would report E967.0 (Perpetrator of child and adult abuse; by father, stepfather, or boyfriend) as the second diagnosis on the claim form.