Pediatric Coding Alert

Question: How do we code office visits for a baby/child with fetal alcohol syndrome? How should we justify frequent visits, and what diagnosis code do we use?

New York Subscriber

Answer: Fetal alcohol syndrome (760.71, noxious influences affecting fetus via placenta or breast milk; fetus or newborn affected by noxious substance transmitted via placenta or breast milk) is no different from other conditions in which behavioral and medical problems intermix. Much of the pediatricians time with the family in the first days of the diagnosis will be spent on counseling. To receive fair reimbursement for this time, pediatricians should document carefully. When counseling consumes more than 50 percent of the visit with the family, time should be used to determine the level of evaluation and management service. CPT outlines the following time definitions for established patient office visits: 99212 (10 minutes), 99213 (15 minutes), 99214 (25 minutes) and 99215 (40 minutes).

Fetal alcohol syndrome can be difficult to diagnose, particularly in neonates, and there is no simple test to verify the condition. Do not use this diagnosis lightly, or you risk inappropriately labeling the child. For newborns up to 28 days suspected of having fetal alcohol syndrome you may use diagnosis codes V29.3 (observation for suspected genetic or metabolic condition), V29.8 (observation for other specified suspected condition) and V29.1 (observation for suspected neurological condition).

Diagnosis of fetal alcohol syndrome is made by a combination of morphological features, including facial and body characteristics. Typically, affected children are soft in terms of deficits problems may not appear severe but if the pediatrician is comfortable with a diagnosis of fetal alcohol syndrome and has shared this with the family, 760.71 should be included on all claims forms that apply to encounters in which the disease plays a role. After the diagnosis is definite, its use can facilitate payment of extra sessions.

Note that ICD-9 code 760.71 applies to fetal, newborn and infant age groups. Many office visits will focus on a specific problem, such as developmental delay, that is caused in whole or in part by the condition. These visits should include as a primary diagnosis the problem on which the visit is focused, with 760.71 as the secondary diagnosis.