Pediatric Coding Alert

Pediatricians are all too familiar with the syndrome: The worried parent, especially the new one, who wants to bring the baby in just to make sure everything is okay. Maybe its a six-month-old whose mother thinks is teething. Maybe its a one-year-old who is cranky and maybe he has an ear infectioncould you just check? Maybe its a three-month-old who is spitting up. 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. You cant bill for parental anxiety. There is no such code. But especially when babies are concerned, there could be problems that arent immediately apparent, so you absolutely have to see the child if the parent is worried, sources tell us.

A lot of new parents come in because they need reassurance, says Doris Weir, CMM, office manager for Washington Pediatric Group of Sewell, N.J. And its very important to see every child if the parent calls in with anxiety, she says. Until the child is examined, you dont know whether the concern is warranted. And with babies, its especially hard to know. The mom could say the baby seems extra sleepy. That may not sound like much, but it could be.

Likewise, many new parents will bring in the child the first time he or she has a runny nose. This may be the childs first cold and usually doesnt necessitate an office visit. But, says Weir, you need to see the child anyway if the parent calls. In other words, pediatricians have to see these patients because they dont know whether the visit is necessary until after they have done the examination.

So how do you code the visit in terms of a diagnosis? Theres always some kind of symptom, says Weir. This is why its so important to get the parent to be as specific as possible about why he or she was concerned. The baby just wasnt acting right, is okay for starters, but you need to probe to get more specifics.

Worried Well Coding

There are two diagnosis codes that might seem appropriate for these cases: V65.5 (person with feared complaint in whom no diagnosis was made) and V71.9 (observation for unspecified suspected condition).

Also known as worried well, V65.5 is an excellent code for pediatrics, says Thomas A. Kent, CMM, president of Kent Medical Management in Dunkirk, Md., and former office manager of a pediatric practice. Worried well is not associated with hypochondria or psychological illness, he explains. Here are three examples from Kent in which V65.5 would be appropriate.

1. Just to make sure. A mother brings her child who recently got over a cold to the pediatrician prior to a cross country trip to see grandmotherJust because I want to make sure everything is OK, the mother tells you. There are no signs, symptoms or problems. This is a perfect place to use V65.5 all by itself because there is no other problem present, says Kent. The parent may have to pay for this visit as insurance will often (but not always) deny payment for this diagnosis code, acknowledges Kent. This is fine, he says. If the child is well then the parent should pay for the visit. He emphasizes that this is not a case in which you should feel sorry for the parent.

2. Pulling at ears. 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 a 99214 (office or other outpatient visit for the evaluation and management of an established patient, which requires decision-making of moderate complexity) based on the extensive time spent. To support that fourth level, Kent recommends using V65.5 as the secondary diagnosis, along with otalgia (388.71) as the primary diagnosis. If the visit does not warrant extra effort, and you are only coding 99213, then you can use 388.71 alone as that will support the CPT code and also is legitimate. Save the worried well for special situations to indicate abuse of services or to support a 99214 with a real sign or symptom but no definitive finding, says Kent.

3. Abuse of services. A parent in an HMO or on Medicaid habitually brings in a child when there is no problem. In this situation, you can use V65.5 to create a feedback loop at the health plan, Kent explains. A health plan nurse will be assigned to discuss the proper use of physician services with the parent, he says. This way the pediatrician does not have to tell the parent to stop coming in so often, which can create liability problems.

Billing For Parent Concerns

It is very important to push to find out what the parents are worried about, says Richard H. Tuck, MD, FAAP, of Primecare Pediatrics in Zanesville, Ohio. Get them to be as specific as possible about the illness they are afraid the child has, he says. This way, you can code that suspected diagnosis first and V65.5 second, he says. While this would seem to be contradictory (V65.5 is specifically for when no diagnosis is made), this is what tips off the insurance company that there was a specific concern, he adds.

The best example of this scenario, says Tuck, is the child who is fussy and who has had otitis (382.9) in the past. The parent says, I think my child might have an ear infection. If the pediatrician finds no ear infection, he or she would code one of the otitis diagnosis codes first, and V65.5 second, says Tuck. Is this telling the insurance company that there is a diagnosis, and that there isnt, at the same time? Not really, says Tuck. All you are doing is telling the insurance carrier what the feared condition in V65.5 is.

Tip: Many insurance companies do not pay V codes when used as a primary diagnosis, so coding the feared condition first will solve that problem.

Code V71.9 (observation for unspecified suspected condition) is not appropriate when there are any symptoms or signs at all. It is defined as a category to be used when persons without a diagnosis are suspected of having an abnormal condition, without signs or symptoms, which requires study, but after examination and observation, is found not to exist.

There is a very important point to remember in this discussion. Most of the time when the parent thinks that something is wrong but doesnt know what it is, something is wrong, says Tuck. The times when the parent wants a child checked and nothing is wrong dont happen often.

Infants

Many pediatricians attribute non-specific crying in very young infants to colic (789.0). They use the diagnosis code for the symptom as the primary diagnosis, followed by V71.8, which is for ruling out a specified suspected condition, to show that the diagnosis actually is not present. Fortunately, pediatricians are not having a hard time getting reimbursed for these visits in newborns. Perhaps insurance companies recognize that this is a vulnerable period for their subscribers as well as for the babies.

For newborns (babies under 30 days old), Kent recommends the V29.x series. These codes are for observation for a suspected condition in the newborn. In correct coding, you can use the V29.x code first and alone. In real life practice, however, it would be better to use the sign or symptom first, followed by the V29.x because many insurance plans dislike V codes.

Finally, Kent stresses that the otalgia diagnosis can be used for most any situation in a newborn. Do not use worried well for small babies, he says, noting, Who is to say the infant does not have irritability caused by ear pain?