Pediatric Coding Alert

Jennifer Bell, practice administrator for Baylor Pediatric Center in Dallas, TX, who always uses the same diagnosis code for the recheck that was used for the original visit. If you put follow-up as a diagnosis, the carrier would say, Follow-up for what? It could be for the ear infection, the gastrointestinal virus, or the upper respiratory infection. I would definitely recommend that people use the original diagnosis code. You could use the V code as a secondary diagnosis, says Bell, but its unlikely to make any difference: The insurance company probably wouldnt look below the primary diagnosis.

However, for the recheck, the pediatricians, for example, write otitis mediaresolved on the notes that are given to the billers, says Bell. There isnt any resolved code, but this way we know to go back to the original otitis media diagnosis.

Charles Scott, MD, FAAP, a regional CPT coding resource physician for the American Academy of Pediatrics, agrees with Bell. I usually use the clinical condition for which the patient first came in when I code a recheck, says Scott, who practices with Medford Pediatric & Adolescent Medicine in Medford, NJ. If the child had otitis media, I would still use that for the follow-up.

While V67.9 (unspecified follow-up examination) may be theoretically accurate, insurance companies dont recognize all the rules, he says. This would be clear-cut if the carriers adhered to all the guidelines.

But even if the insurance companies dont play by the rules, in this case Scott believes there is good rationale for using the original diagnosisbeyond the fact that that is what you will get paid with. Otitis media is the reason for the child coming in, and its the reason for them coming back for a follow-up, he reasons. The plans know theyre paying for a second evaluation. He adds that there are no global fees for this kind of work. In pediatrics, we basically only get compensated for what we do, he says.

Examples of other conditions that call for rechecks include cellulitis, when a doctor wants to see if oral antibiotics are clearing up an infection; corneal abrasion, when the doctor needs to check on healing; pneumonia, when the doctor needs to listen to the lungs; and reactive airway disease, especially in small babies. All of these rechecks would get the original diagnosis code, even if the original problems had cleared up, says Scott.

Hospital Rechecks

The same concepts apply to rechecks done after hospitalizations. If a child is coming to the office for a visit after being hospitalized for something like tastroenteritis or pneumonia and then comes to see you and the condition is resolved, you should use the original diagnosis code, says Richard H. Tuck, MD, FAAP, founder of the RBRVS PAC and in practice in Zanesville, OH. This wouldnt apply to hospitalizations which were for conditions which had global surgical fees, Tuck notes. For example, if the child were hospitalized for appendicitis, the child would return to the surgeon for rechecks, which would be covered in the surgical fee.

Procedure Codes, Too

The next question is, what level office visit (99211-99215) should you use for the original visit and the follow-up visit? If the follow-up visit is problem-focused, meaning you are addressing only the original condition, then you should use a second-level office visit, says Scott. This will always be true if the problem has cleared up and there are no other problems. Sometimes, the problem may not have cleared up, but is still simple enough to require only a second-level visitin other words, you are not looking at other body areas or dealing with more complicated medical decision-making. Most of the time, however, if a childs otitis, for example, has not cleared up after treatment, you probably will be coding a Level 3 or higher office visit, depending on the circumstances.

So when would an otitis media recheck qualify as 99213? If they come in with other symptoms when youre following up on the otitis, says Scott. If they have wheezing, or abdominal pain, for example, he says. When would an original otitis media visit qualify as 99214? For example if they have otitis media with wheezing, coughing, fever and listlessness he says. Just a fever with otitis media would not justify 99214.

Coding for Counseling

Another reason for coding a recheck as a third level or even a fourth level is counseling, notes Tuck. If a child came in for a recheck of otitis media and had recurrent episodes, this may be when you have an extensive discussion about the anatomy of the ear, the parents concerns about future hearing loss, and treatment options including tubes or antibiotics, he says. If this discussion takes up more than 50 percent of the time spent in the encounter, you can use time to raise the code to a higher level, notes Tuck.