Pediatric Coding Alert

The problem frequently arises in pediatrics: a baby is fussing and the mother is concerned about a possible ear infection. She calls asking for an appointment, and tells the receptionist that she is afraid her child has his third ear infection, and she wants to get it seen as soon as possible. She tells the nurse when she gets in the exam room what her concerns are. The pediatrician examines the child, but the ears turn out to be fine.

Laura C. Vibert, medical assistant for John Fote, MD of Rocky Hill, CT, has been caught in this situation before. If you code it 99213, with a diagnosis code of V20.2 (routine infant or child health check), the claim is rejected, she says. If you code it with an ear infection code, nothing in the chart substantiates this diagnosis.

The mother says the child is irritable, says Vibert. Maybe the baby is pulling on his ear, she notes. But in any event, when the baby comes in, it turns out to be mere fussiness or a behavioral thing, and theres nothing to document medically.

Vibert is concerned because she knows the code has to be backed up by documentation. We cant make something up, she emphasizes. Thats fraud.

First, say many coders, the V20.2 will not get the visit paid. While V20.2 might make sense in a way, it really is only for well-visits. Well-visits have different procedure codes (preventive medicine services, new patient, 99381-99385, and established patient, 99391-99395) and will not go with V20.2. A better option would be to use a screening code, a code for ear pain or observation for otitis, or, if possible, determine whether there is another medical cause of the babys irritability and code for that.

1. Use a screening code. This is the recommendation of Sheilla Hume, insurance manager for Raleigh Group Pediatrics, a four-pediatrician practice in Memphis, TN, who uses V80.3. This code is for screening for an ear exam, explains Hume. We have no problem getting reimbursed using this code. The screening codes are very useful for various problems when it turns out there is no problem. When you have a child younger than two or three years old, they cant tell you, My ear hurts, notes Hume. The mother has to take a guessand knowing that ear infections only get worse, wants, quite rightly, to get it treated right away.

2. Keep looking. This is the other option, one favored by Tina Barnes, insurance supervisor for Pediatric Associates of Southern Indiana, a three-pediatrician practice in New Albany, IN. I leave it up to the doctor, she says. But, what we encourage our doctors to do is to keep looking. In fact, the pediatrician often does find other problems causing the behavior that is concerning the mother, she says. It could be an upper respiratory infection, it could be allergic rhinitis, it could be teething pain. There are too many possibilities to list.

The point is that something is usually there that warrants a specific diagnosis code, she states. While its true that the mother brought the child in worried about the ears, and nothing else, the pediatrician has to look for other problems. We try to dig a little further, says Barnes. And we usually find something.

3. Worried well. Our examination of ICD-9-CM reveals that there is, indeed, a code for a person with feared complaint in whom no diagnosis was made. The code is V65.5. It encompasses the following: feared condition not demonstrated, problem was normal state, and a condition called worried well. We have not found anyone who is using this code; however, it seems to be a possible solution. You might also use the otitis diagnosis first, followed by the worried well diagnosis; this would indicate that otitis was suspected but not found.

Tip: While the worried well diagnosis code is correct coding, many insurance companies wont pay. Some billers reserve this code for when they need to discourage a patient from abusing the services of the physiciannot the case in this scenario with the worried mother.

4. Use the diagnosis code for ear painotalgia. This is 388.70. Used with the office-visit CPT code, usually 99213, you should be reimbursed.

5. Use the appropriate diagnosis code for otitis (such as 381.01) followed by V29.8: observation of infant for suspected condition, specified. Ideally, the V29.8 should go first, but because some insurers dont like V codes, listing it second is another way of saying that the pediatrician suspected otitis but didnt find it.