Pediatric Coding Alert

Question: Because her 3-month-old infant "is pulling on her ears," a mother presents with the baby for a suspected ear infection. Although the baby has had three ear infections, the pediatrician finds no signs of ear infection at this established patient visit. Which diagnosis should I use to explain the service?

Florida Subscriber

Answer: Some parents automatically assume that when a baby pulls at her ears she has an ear infection. You should assign the correct level of E/M service (99212-99215, Office visit for the evaluation and management of an established patient). Because the mother brings the child in for otitis media (OM), you could use 382.00 (Acute suppurative otitis media without spontaneous rupture of ear drum) with V65.5 (Person with feared complaint in whom no diagnosis was made) to indicate the pediatrician did not find the condition. If you prefer not to use the OM diagnosis (382.00), you could report 780.99 (Other general symptoms) and V65.5. To avoid payer denials for a "worried well" depending on what symptoms the mother describes, you could alternatively use 388.70 (Otalgia, unspecified; earache NOS) and 780.91 (Fussy infant [baby]).

- Answers to You Be the Coder and Reader Questions answered by Catherine A. Hudson, RMA, RPT, billing specialist at Cumberland Pediatrics PC in Marietta, Ga.; Richard Lander, MD, FAAP, pediatrician at Essex-Morris Pediatric Group in Livingston, N.J.; and Linda Walsh, senior health policy analyst with the American Academy of Pediatrics division of healthcare finance and practice.