Pediatric Coding Alert

Linda Kortanek, office manager for Northpoint Pediatrics, Indianapolis, IN, wants to know what order to use in listing ICD-9 codes on the HCFA 1500 claim form. She writes: We are curious to know your explanation of the significance of numbering the ICD-9 codes in regard to the filing of a HCFA claim form. We have read the code book, but it is unclear to us. Any help you can give would be greatly appreciated!

Indeed, determining the primary complaint, and correctly listing the codes, can seem complicated. For example, it isnt unusual for a child to have three diagnoses, such as otitis media, conjunctivitis, and pharyngitis. What you dont want is for the pediatrician to simply circle three diagnoses.

The problem is that you only have one office visit. And if the pediatrician was dealing with three separate problems, you want to make sure those all get tied to that one visit. Otherwise, what should be a level 99214 exam will be downcoded by the carrier to a CPT 99212 .

You should list the most significant diagnosis first, explains Thomas Kent, CMM, office manager for Esther Y. Johnson, MD, FAAP, of Dunkirk, MD. That would be the diagnosis that involves the greatest part of the pediatricians time and medical decision-making. Then, continue to list all of the diagnoses.

But where do you list them first? The answer is, next to the procedure code that they are supporting.
Note that each CPT code may get a different diagnosis code, and one CPT code may get more than one diagnosis code supporting it. It is essential that the diagnosis code support the procedure codes. For example, if you performed a urinalysis, you would not put a diagnosis of foreign body in nose next to that CPT code.

So, this is how you would list the supporting diagnoses on the HCFA 1500 form. In the middle, under section 21, there are four places for ICD-9 codes. This is not where the list order is important. Below that, under section 24, you list the CPT codes and ICD-9 codes. This is where the order of diagnosis codes matters. Column 24D is for CPT codes, and beside that, you can put any modifiers. Column 24E is for the diagnosis codes, but there is only room for four digits. So next to the appropriate CPT code, you put the number that you assigned to the relevant ICD-9 code in section 21.

Sample Case

Lets say a child comes in with several problems. There are three diagnoses: acute suppurative otitis media (382.00), extrinsic asthma with status asthmaticus (493.1), and urinary tract infection (599.0). The services that the pediatrician provided are a fourth-level office visit (99214), 30 minutes of prolonged services (99354) for all three diagnoses, nebulizer treatment (94640 and J7620) for the asthma attack, and a urinalysis (81015) and urine culture (87087) for the UTI.

The HCFA 1500 form has four slots for diagnosis codes in box 21. You can put the diagnosis codes in whatever order you want (the order in which you list them in box 21 will not affect your reimbursement). For purposes of this example, we are putting the codes in the following order:

1. 382.00
2. 599.0
3. 493.1
4. no fourth diagnosis, so nothing needs to be listed

Next, in box 24, there are two columns: D (procedures, services or supplies) and E (diagnosis code). In column D you should write out the actual codes that tie in with the procedure, service or supply. In column E you should list the corresponding number next to the diagnosis code listed in box 21 (as shown above).

Tip: Be sure to list the diagnosis code numbers from box 21 according to their seriousness, starting with the most serious and decreasing thereafter. This is where the order of the diagnoses counts to ensure proper reimbursement.

Below is an example of how the above case should be recorded in box 24 of the HCFA 1500 form:

		D   	          E
		99214		3 2 1
		94640		3
		81015		2
		87087		2
		99354		3 2 1
		J7620		3

Section 24 clearly reflects that whatever the pediatrician was doing, the asthma attack was the most significant diagnosis, followed by the urinary tract infection, and then the otitis media.

Its not necessary to look creatively for different diagnoses -- one is enough, says Kent. But it is essential to get all the diagnoses on the HCFA 1500 form. Even though some insurance companies only look at the first diagnosis for each service, if they ever do an audit, then theyll check all four.

Incidentally, you dont need to worry about what the primary complaint, is, says Kent. You dont need a symptom when youve got the diagnosis. However, the primary complaint is important if all you have are the symptoms, and you do not yet have a definitive diagnosis.