Pediatric Coding Alert

Pediatricians are familiar with unnecessary appointments. The mother is so worried about her childs health that she brings him in for a sick visit on a regular basis, even though the child isnt usually sick. This is a common occurrence. What diagnosis code do you link to the office visit (99201-99205 for new patients, 99212-99215 for established patients) when the mother thinks there is something wrong, but the 9-month-old cant tell you what, if anything, hurts? Pediatricians can get paid in these cases if they talk to the mother to find out exactly what behavior made her think something is wrong, and then code the sign or symptom closest to that.

Use whatever sign and symptom is closest to what the mother is saying, says Mark S. Reuben, MD, FAAP, president of Reading Pediatrics, an eight-pediatrician practice based in Wyomissing, Pa. This takes some probing on the physicians part.

Reuben uses ICD-9 code 520.7 (teething syndrome) with the office visit because most of the time, this is exactly what the problem is. Its so common, weve put it on our superbill, he says. Occasionally, an insurance company will deny the claim, saying that the patient does not have dental coverage. Then, says Reuben, you need to explain to the company that it is not a dental problem.

The Symptoms, Signs, and Ill-Defined Conditions section of ICD-9 (780-799) is replete with various diagnoses you can use, says Ricardo Garcia, CPC, MBA, CEO of DRG Associates, a Denver-based consulting company that bills for a 750-physician group with 200 pediatricians. But you need to hone in on the most specific one by talking to the mother. Find out why the mother thinks the baby is fussy, he says. As a biller, he knows that the more accurate the diagnosis is, the better the chance that it will be paid without any problems. You need to pinpoint why the mother thinks the child isnt normal, he says. The point is to get to the difference between what she views as normal and what she views as not normal.

The worried well diagnosis code, V65.5, is not recommended by Garcia. In my experience, its never paid, he says.

But some coding experts think V65.5 is a good code to use. True, it is often denied payment, says Thomas Kent, CMM, president of Kent Medical Management, a practice management and coding consulting firm in Dunkirk, Md. But it pays off in the long run because the parents will be less inclined to come in for minor problems if they have to pay for a non-covered visit.

Richard H. Tuck, MD, FAAP, founding member of the AMA RBRVS RUC and a pediatrician at PrimeCare of Southeastern Ohio, recommends listing two diagnosis codes in this case, with the V65.5 code being the second diagnosis. The first diagnosis should be the problem the parent is concerned about, he says.

Educate the Parents Pediatricians often ask if there is any way to discourage parents from bringing children in on a much too regular basis. Obviously, pediatric practices dont want to dissuade parents from visiting when the child does not seem well. Often, mothers have an intuitive sense about their childrens health. But there are many parents who abuse the pediatricians services because the $5 or $10 copay is so low. The solution, says Mark S. Reuben, MD, FAAP, president of Reading Pediatrics, a private eight-pediatrician practice in Wyomissing, Pa., is to use this time to educate the parent on when she should bring the child in. You dont want to denigrate them for bringing the baby in, he says. But you dont make a lot of money on these little office visits, and you have the added problem of a full-to-bursting schedule. So I use it as an educational sessionwhat are the signs and symptoms that warrant a trip to the pediatrician, says Reuben. Not only are these low-level office visits taking up your time that you could be spending with patients who are truly sick, but more to the point, they are extending your day so that you will be working late and having to pay staff to work late. This is why its a good idea to spend some time helping the parent be more independent. You can recoup some reimbursement for this time by upcoding the office visit if you spend at least 50 percent of the encounter time on counseling. You also can notify the managed care plan that a parent is abusing the pediatricians time. The plan usually will have a nurse call the parent to discuss proper usage of physician services. This is one area where the HMO will play the tough guy in your support.