Pediatric Coding Alert

If a pediatrician orders a test to rule out a certain condition, what kind of diagnosis code should you use? If you suspect that a problem exists, and the tests show that it does, what effect does this have on the diagnosis code? This is a recurring question, especially in pediatrics, because babies cant help with the history by telling you how they feel.

You cant code based on the lab finding or the x-ray result alone, says Patricia S. Wildman, RRA, clinical reimbursement auditor at Childrens Hospital in Boston, MA. But, if the diagnosis is not known before the test is done, you should code based on the signs and symptoms noted by the pediatrician when the test was ordered, she advises.

A screening is a screening is a screening, regardless of how it comes back, says Alison Morris, CCS, coding team leader for Georgia Physician Services (six pediatricians, more than 50 physicians altogether) of Fayetteville, GA. You should code the sign or symptom only.

Code the reason the patient is having the test, Wildman asserts. If a diagnosis is not known, then code the sign or symptom that brought the patient in for the test.

Lets say a child has a cough and a fever, and you want to rule out pneumonia. You should use the ICD-9 code for a cough (786.2) for the primary diagnosis, and the code for a fever (780.6, except in newborns, when you should use 778.4) for the secondary diagnosis code, says Morris.

Note: It is important to avoid using unconfirmed diagnosis codes because insurance companies maintain a database of all of these codes. When these patients then apply for life, health, or disability insurance, the company will look for any problems the patient had in the past. For example, dont use the diagnosis for tuberculosis (011.90) for a screening PPD; instead, use the diagnosis code for screening for tuberculosis (V74.1). Otherwise, your patient will end up with a permanent history of having had tuberculosis on his or her medical record, and this could have serious adverse effects on future insurability.

Secondary Diagnosis Codes

There are no rule-out codes, but secondary diagnosis codes can be very useful in a typical rule-out scenario. No, insurance companies dont always pay attention to the secondary diagnosis codes. If youre filing electronically, says Morris, theyll only pick up the first one. But its good to have the additional code on the claim form anyway.

In the above example, 786.2 should be the first diagnosis, but having 780.6 on the form will help. If you had to order a lot of chest x-rays during a particularly bad cold season, and someone reviews your charts, the fact that the child had a fever as well as a cough will be cleareven if the insurance company missed it when they processed the claim.

Follow-up Diagnoses

Lets say the x-ray shows that the child has pneumonia. You see the patient for a follow-up, and want another x-ray to see if the lungs have cleared up. This time, there only needs to be one diagnosis code for the test: pneumonia. You ask yourself the routine questions a coder asks, says Morris. Why is the patient coming in for a follow-up? Pneumonia is the reason. So pneumonia is the reason for the test. As long as the child is being treated for pneumonia, you should use a pneumonia code (and there are many, depending on what kind of pneumonia the child has) for the follow-up x-rays as well as the office visit, says Morris.

If the patient comes in for follow-up of pneumonia after having completed treatment, and the x-ray no longer shows pneumonia, then you could use V67.59 for follow-up exam following other treatment, says Wildman. If the child is no longer being treated for the pneumonia and the x-ray is normal, you cannot code pneumonia again.

What if you are following up a patient after surgery? You should use the code V67.0, for follow-up exam following surgery, if there are no new or recurring problems found, says Wildman. The V67 codes are for follow-up after completed treatment of a condition that has healed, she says. For example, a visit for a patient coming in for a six-month follow-up visit after surgery for osteosarcoma with no recurrence would be V67.0, says the clinical auditor. This is not during the healing phase, but after completed treatment, she notes. In addition to the V67.0 code, you should also code the history of bone neoplasm (V10.81). If, on the other hand, there was a recurrence, you would code the appropriate osteosarcoma code.

Some veteran coders may realize that there is a potential problem here. In the real world, many insurance companies automatically deny claims with a V code as the primary diagnosis (often, the first code is the only one they read). In the cancer scenario, for example, it is generally accepted to use the cancer diagnosis for up to five years into remission, according to Thomas Kent, CMM, a coding seminar leader for McVey Associates. Then use the V71, V76, or V67 category as a secondary diagnosis, along the V10 category, says Kent. This is an example of artistic codingcoding that worksover technically correct coding, he says. By including the V codes you are still demonstrating that the visit was for follow-up. But youre not putting them on top.

While using V codes is appropriate per coding rules and for compliance, third-party payers dont like them, Wildman acknowledges. Payers may have their own specific guidelines on how to code, she says. What pediatric coders should do, when a payer wont pay a claim because of the way its coded and you know you are following coding rules, is to ask for the insurer to send you their instructions in writing. Then, if you are audited later on, you can justify why you coded something the way you did, says Wildman. In many cases, their requests cause you to be out of compliance, so you need to cover yourself by getting them to put their instructions in writing. To get the claim paid, it helps to send a copy of the documentation with the charge ticket to the payer, she adds. This helps explain why you coded the way you did.

Chronic Conditions

What if the child has a chronic disease, like diabetes, which you are monitoring? You should always code the disease for which the child is being followed, says Wildman. The V67 category is for the follow-up of completed treatment, not for continuous monitoring of a chronic disease, she says. If you are seeing a patient on a regular basis for diabetes, you must use the diabetes diagnosis code the 250 series, and remember that this code needs a fifth digit.

Note: About that fifth digit: the insurance company will request it. Thats because the payer links its frequency guidelines to the specific diabetes diagnosis. However, if you need to see a diabetic more often than the guidelines allowif, for example, there are fluctuations in the blood glucose levelsyou can appeal (and win) a denial on that basis, says Morris.

Family History and Observation Codes

The family history codes (V16 to V19) should only be used as secondary codes. Family history isnt a severe enough diagnosis to justify an office visit, says Morris. If a diagnosis is suspected because of a family history, there are no current symptoms, and the results come back normal, you should use the V71 series of codes, says Wildman. Note that V71 is for observation and evaluation for suspected conditions not found. This category is 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, according to ICD-9-CM.

When using V71 and family history, always use the V71 code as the primary diagnosis, says Wildman. V71 means the results are normal, she notes. Its a good code for observation, but only if the results are normal.

The V29 series is similar to V71, but its specifically for newborns. V29 is for observation and evaluation of newborns and infants for suspected condition not found, according to ICD-9-CM. This category is to be used for newborns, within the neonatal period (the first 28 days of life), who are suspected of having an abnormal condition resulting from exposure from the mother or the birth process, but without signs or symptoms, and, which after examination and observation, is found not to exist.

For example, lets say the mother has a fever immediately after delivery. You need to find out if the baby has an infection, says Morris. So the secondary admitting diagnosis could be V29.0 for observation for suspected infectious condition. If the results show there is no infection, the only discharge diagnosis would be a newborn code (V30 series).

If the baby is admitted as an inpatient or seen as an outpatient for observation of a suspected problem, that, after study, is proven not to exist, a code from the V29 category would be the principal diagnosis. If, during the admission where the baby is born, the baby is suspected of a condition that is proven not to exist, V29 would then be listed as a secondary code with a code from the V30 category (birth codes) as the principal diagnosis.

Tip: Make sure your claim and the hospital claim use the same diagnoses. Also, note that the V29 series is also appropriate for the three-day and two-week newborn office visits, when no problems are present.

The V71 series and V29 series require you to fill out the diagnosis after the test is done. The pediatrician should wait for the results of the test before coding, says Wildman, so the diagnosis can be coded if there is one. Otherwise, you should use the V29 or V71 code as appropriate. Unless they are given a symptom by the ordering pediatrician, the lab, can only code the V71 or V29 code, she says. Depending on who does the lab or x-ray coding and whether they take the office notes from the outpatient visit into consideration, they could code the results if positivethat the pediatrician was asking to be ruled out.

Strictly speaking, you dont have to wait for the lab results to come back to code a claim. After all, pathology reports can take weeks.

Whats Normal?

A coder should never try to determine whether test results are normal or abnormal, cautions Wildman. Even if the test is out of range for normal, it may not mean that the results are abnormal for this particular patient, she says. Only the pediatrician can make that determination.