Pediatric Coding Alert

Pennsylvania Subscriber

 

Answer: This is controversial. The American Academy of Pediatrics (AAP) recommends V67.9 (unspecified follow-up examination), but few insurance companies pay based on that diagnosis. Most practices use the code for the original condition because that best represents the reason for the visit. For example, if a child had otitis media, and you want to make sure the infection cleared after a course of antibiotics, code the otitis media (38x.x) for the recheck. You could use V67.9 as the secondary diagnosis.

Technically, the AAP is correct. "According to the Official Guidelines for Coding and Reporting, you should not report conditions that were previously treated and no longer exist," the AAP says. "Follow-up codes are used to explain continuing surveillance after completed treatment of a disease, condition or injury. They imply that the condition had been fully treated and no longer exists." But if you want to get paid, you have to code the disease.

 

We recommend using the original diagnosis because that is the reason you are seeing the patient. This is entirely in accord with Medicare guidelines: A physician-recommended return to the office is billable. At the time the patient presents, you don't know whether the otitis media, for example, has resolved. 

 

The coding guidelines the AAP references are ICD-9 guidelines. This is one of the reasons for confusion. ICD-9 codes are the province of the World Health Organization (WHO) and the American Hospital Association (AHA). For WHO, diagnosis coding records diseases; using surveillance codes gives a more accurate representation for tracking than do disease codes. For the AHA, diagnosis coding is geared to inpatient coding, which differs from outpatient coding. For example, hospital coders use rule-out coding principles, which allow coding a discharge diagnosis for a rule-out as the actual disease being ruled out. This is not allowed in outpatient coding. 

 

If you bill using V67.9, you may well get a denial from the insurance company. If you are contracted with the payer, and if the payer denied the claim specifically as "patient responsibility," you not only may, but are required to, bill the patient. Otherwise, even if contracted, you can write it off -- but you can't bill the patient.

 

If you are not contracted with the payer, and you bill using V67.9 and the payer denies, you can bill the patient. Sometimes you can appeal, if you feel you have a good case. It's a good idea, however, to have the parent lead the appeal. You can send your chart notes to the insurance company, but it's the parent who has the coverage and the clout to demand attention.