Pediatric Coding Alert

Question: How should I code for a patient whose parent wants to make sure he is ok before going on vacation? Which diagnosis code should I use?

Connecticut Subscriber

Answer: Without a specific complaint, use the V7x.x section (persons without reported diagnosis encountered during examination and investigation of individuals and populations) or the "worried well" diagnosis code (V65.5, person with feared complaint in whom no diagnosis was made). Neither of these codes matches the "sick visit" E/M codes (99201-99215). Therefore, you would have to use a well visit code (99381-99385, 99391-99395). Unless you actually perform a complete well visit during the "vacation check," do not bill for it. Getting paid for the visit is problematic because the procedure code and diagnosis contradict each other. The payer will deny 99212 when linked with V20.2 (routine infant or child health check).
 
One solution is to code the reason for the parent's concern in the primary position, with the "worried well" code (V65.5) in the secondary position. For example, perhaps the child has had otitis media, and the mother wants to have the ears checked before flying. Code otitis media (381.xx) as the primary diagnosis and V65.5 as the secondary diagnosis. Another solution may be to tell the parent that he or she will be responsible for the visit a difficult situation from a customer-service viewpoint and possibly illegal under the contract you signed with the patient's managed care company.
 
A simpler solution is to probe for the reason for the parent's concern to arrive at the sign or symptom you can use as the diagnosis code (493.xx); For example, let's say the patient has had asthma that is well-controlled. The parent wants to make sure that all medication is at appropriate dosing levels prior to leaving for Disneyland, 3,000 miles from the child's pediatrician. The pediatrician can code this visit with the asthma diagnosis code; it is a legitimate medical visit and a legitimate code.
 
In another example, the parent may say she wants the child checked because he has been complaining every now and then of stomach pains, or headaches or excessive tiredness, and she doesn't want something to erupt while on vacation if it can be handled now. Link the symptom diagnosis code with the E/M visit.