Pediatric Coding Alert

 Implement this ICD-9 action plan to decide which diagnosis should go first

Relying on a computer system to rank diagnoses could mean your claims don’t represent medical necessity. To fix the problem, code based on these ICD9 guidelines.
 
When faced with multiple outpatient ICD-9 codes, you may not know which one to list first. “Should I enter them in the order the provider lists them, or should I start with the presenting diagnosis?” asks Michelle Zilak in the billing department of Western New York Pediatrics in Orchard Park. Here’s what ICD-9 gurus suggest.

List the Most Important Reason First

You should first code the main or most serious diagnosis, says Jeffrey F. Linzer Sr., MD, FAAP, FACEP, associate medical director for compliance and business affairs at EPG -- Children’s Healthcare of Atlanta at Egleston. “The primary diagnosis should be either:

 • the primary reason for the encounter or
 
• the condition with the highest risk of morbidity/ mortality that the physician is addressing at the encounter.”

Best practice: The pediatrician can help solve the coding dilemma by indicating the primary diagnosis. But if she doesn’t, “the coder should be able to extract the information from the chart,” Linzer says. Nontrained coders should query the physician as to the primary diagnosis, he says.

Choose Definitive Over Presenting

Be careful that you don’t assume the primary reason for the encounter is the same as the presenting diagnosis. Do this: Instead of focusing on the presenting problem or chief complaint, look for the pediatrician’s definitive diagnosis.
 
Here’s how: A child comes in because of fever and ear pain, and the pediatrician finds acute suppurative otitis media. You should first code the definitive diagnosis (382.00, Acute suppurative otitis media without spontaneous rupture of ear drum), not the presenting diagnoses (780.6, Fever; and 388.70, Otalgia, unspecified). Because the ear pain and fever are “inherent” in the diagnosed condition, you should not separately code them, Linzer says.

Code Symptoms in 2 Instances

Some circumstances, however, do warrant assigning additional ICD-9 codes for a patient’s symptoms:
 
1. If the child’s symptoms are not part of the disease process, you should separately code them. A classic example of this involves a child who presents with pneumonia  and vomiting. In this case, coding the symptom of vomiting in addition to the pneumonia shows that the child is sicker than if he just had pneumonia, says Richard H. Tuck, MD, FAAP, a pediatrician at PrimeCare of Southeastern Ohio. “Listing both ICD-9 codes (such as 486, Pneumonia, organism unspecified and 787.03, Vomiting alone) would potentially support a higher level of E/M code.”
 
2. When a pediatrician does not establish or confirm a diagnosis, you may report the patient’s symptoms. Suppose a pediatrician sees a child who has just hurt his arm, and the physician finds no fracture. “Following ICD-9 guidelines, you would use the signs and symptoms and code for the [fore]arm injury (959.3, Injury, other and unspecified; elbow, forearm and wrist),” Linzer says.

Double-Check Your Submission With This Strategy

If you’re in doubt over which ICD-9 code to list first -- or at all -- on a claim form, check whether the diagnosis supports medical necessity for the service or procedure. Go in-depth as one auditor finds an ICD-9-CPT code mismatch that spells trouble.
 
Consultant Maxine Lewis just finished an audit of one practice that used the same ICD-9 code for ankle pain (719.47, Other and unspecified disorders of joint; pain in joint; ankle and foot) with every ankle-related visit. On average, the office was billing $600 per visit (e.g, 99214, Office visit for the evaluation and management of an established patient …), and some visits were as high as $1,200 for the E/M visit plus supplies (e.g., S8451, Splint, prefabricated, wrist or ankle).
 
Simple foot pain shouldn’t require $600 worth of services, much less $1,200, says Lewis, with Medical Coding Reimbursement Management in Cincinnati.
 
In some cases, the patient probably had a fracture (such as 824.8, Fracture of ankle; unspecified, closed) instead of simple ankle pain (719.47), but the diagnosis code did not reflect that, Lewis says. If you’re using a superbill, it may attach ICD-9 codes in random order, but the coder has to make sure the most important code goes first.
 
Bottom line: Diagnosis coding determines the medical necessity for what’s being done. If ICD-9 codes don’t support the CPT codes, take a closer look at your claims.