Pediatric Coding Alert

Many private payers have mental-health restrictions for their managed care plans. They may refuse to reimburse pediatricians for mental disorders (diagnosis codes 290-319), saying that these conditions can only be treated by a mental-health professional. Although this it not true in scope-of-practice or CPT terms, it helps payers control use. You can facilitate payment by billing the most appropriate code, and, if the payer refuses to pay, collecting from the parent.
 
Fussy baby: The "fussy baby" diagnosis is the least troublesome, partly because there is little question of an infant as a mental-health patient, notes Carel Martin, CPC, biller for the Cle Elum Family Medicine Center in Cle Elum, Wash. "We assume a fussy baby isn't having a behavioral problem," she says. "We use abdominal pain because usually what a fussy baby has is colic." ICD-9 contains no code for "fussy baby" or for infantile colic. Although not all pediatricians agree that all fussy babies have colic, the ICD-9 index lists 789.00 (Abdominal pain, unspecified site) for infantile colic.
 
Toddler temper tantrums: When the pediatrician spends time discussing how to handle toddler temper tantrums with the parent, use 312.1x (Undersocialized conduct disorder, unaggressive type). This might seem an extreme diagnosis for a toddler, but it is the correct diagnosis for temper tantrums, says Richard H. Tuck, MD, FAAP, founding chairman of the AAP coding and reimbursement committee. "This is a perfect example of the ICD-9 index leading you to the correct diagnosis," he says, noting that the proper way to use ICD-9 is the index, not to hunt through codes. Look under "tantrum" in the index, and it directs you to 312.1. 
 
An older child with attention deficit hyperactivity disorder (ADHD) in its mildest form might have only a mild attention problem that manifests itself as problems in school (313.83, Academic underachievement disorder), Tuck says. At its extreme, however, a clear clinical diagnosis that requires medication calls for an ADHD diagnosis (314.xx, Attention deficit disorder).
 
Pediatric coders should pay attention to 313.x-316, which apply to childhood and adolescence. For example:

  313.3 (Relationship problems) is for sibling rivalry
  315.4 (Coordination disorder) is for clumsiness
  313.82 (Identity disorder) is for adolescents who have, for example, "uncertainty about career choice, sexual orientation, moral values."
  
Other useful V codes include: 
  V61.0 Family disruption
  V61.20 Counseling for parent-child problem, unspecified
  V61.8 Other specified family circumstances
  V61.9 Unspecified family circumstance
  V62.3 Other psychosocial circumstances; educational circumstances
  V62.82 Bereavement, uncomplicated
  V69.8 Other problems related to lifestyle.
Code the condition found, regardless of whether a payer will pay. "If it is a behavioral problem, you have to code the behavioral problem," Martin says. "Then, if the payer won't cover that diagnosis, bill the parent." Use the most appropriate diagnosis codes [...]