Pediatric Coding Alert

Question: In the July 2004 Pediatric Coding Alert reader question "Include Tube Check in Office Visit," why did the coder choose 388.70 for the diagnosis when the scenario didn't mention that the 3-year-old child had ear pain?
 
I used V65.5 for a similar situation in my office. The mother thought the child might have an ear infection because he was pulling on his ears. But the examination revealed normal ears.

Alabama Subscriber
 
Answer: Even though the pediatricians in both examples found no infection, you should still use otalgia (such as 388.70, Otalgia, unspecified) as the primary diagnosis. Children don't normally pull on their ears. The behavior indicates that  a disturbance, such as fluid, infection or pressure-equalizing tubes in a patient who has them, is causing the child discomfort or pain. Therefore, otalgia appropriately describes the child's condition.
 
You could also assign V41.3 (Problems with special senses and other special functions; other ear problems) in the secondary position to denote other ear problems. Code V41.3 tells the insurer that the pediatrician found no reason for the ear pain but concluded that some other problem exists.
 
Alternatively, you could report 388.70 and V65.5 (Person with feared complaint in whom no diagnosis was made). Using V65.5 as a secondary diagnosis informs the payer that the parent feared that the child had ear pain, but the pediatrician found no problem.
 
You could also use V65.5 as the secondary ICD-9 code with 382.00 (Acute suppurative otitis media without spontaneous rupture of ear drum) as the primary diagnosis. This combination indicates the mother was concerned that the child might have an ear infection (382.00), but despite her worries the child was well (V65.5 "worried well").
 
You shouldn't, however, omit the otalgia or otitis media diagnosis as you suggested. Because 388.70 identifies the feared condition, coding ear pain or infection paints a more accurate picture than V65.5 alone does.
 
And because Medicare designates V65.5 as a secondary diagnosis in the ICD-9 manual, you should only use the "worried well" in the primary position when no better diagnosis exists. For instance, a mother brings her baby in "just to make sure he is well enough for a cross-country trip to grandma's house." Because the infant exhibits no signs, symptoms or problems, you should use only V65.5.

 - Answers to You Be the Coder and Reader Questions provided by Susan W. Carlson, CCS, CCS-P, CPC, HIM compliance specialist at Dominican Hospital in Santa Cruz, Calif.; and Victoria S. Jackson, administrator at Southern Orange County Pediatric Association in Lake Forest, Calif. CPT Assistant information provided by Kim Kieke, CPC, in Austin, Texas.