Pediatric Coding Alert

In pediatrics, often there is no definitive diagnosis. In these cases, use a signs and symptoms diagnosis code (usually 780-789) for the visit. However, if a definitive diagnosis is known by the end of the encounter, report that reason for the visit. It's important to differentiate between encounters that have no diagnosis and those that do, because coding rules require as much specificity as possible.
 
"Base the diagnosis on the highest level of certainty at the time of the encounter," says Jeffrey Linzer Sr., MD, FAAP, MICP, AAP representative to the ICD-9 editorial advisory board, professor of pediatrics at Emory University and director of emergency medicine at Children's Healthcare of Atlanta and Hughes Spalding Children's Hospital.

When a definitive diagnosis exists, there is no need to pile on symptoms or, in most cases, multiple diagnoses.
 
For example, a 4-year-old comes in with a fever (780.6), cough (786.2), and malaise (780.79, Other malaise and fatigue). The diagnosis is viral influenza (487.1 , Influenza; with other respiratory manifestations). Claim only influenza, the definitive diagnosis. Do not include the symptoms.
 
In another example, a newborn has yellow skin and yellow eyes. Based on clinical findings, jaundice is diagnosed, says A.D. Jacobson, MD, FAAP, medical director of Pediatric Associates in Phoenix. Usually, the only diagnosis on the claim form is jaundice (774.0-774.7). Use the symptom as the definitive diagnosis; laboratory test results are unnecessary.
 
In a third example, an 8-year-old with chronic asthma comes in with wheezing (786.07) and nasal congestion. An upper respiratory infection (URI) is diagnosed (465.9, Acute upper respiratory infections of multiple or unspecified sites; unspecified site), which should be the primary diagnosis on the claim form. In this case, list an asthma diagnosis (493.0x), in the secondary position because the URI triggered the asthma.

Sometimes the definitive diagnosis is unknown at the end of the encounter because the pediatrician is waiting for laboratory results. In that case, code only what you know at the end of the encounter or by the end of the day. Many of these diagnoses are clinical. A clinical diagnosis is one made by physician examination. A diagnosis that is made with laboratory or imaging testing is a laboratory diagnosis.
 
Cough/fever/tachypnea or pneumonia: For example, an 8-year-old comes in with a cough (786.2) of three weeks and a low-grade fever (780.6). The pediatrician listens to the lungs and hears abnormal breath sounds; the patient has tachypnea (786.06). If the doctor prefers to base the diagnosis of pneumonia on lab results, he or she orders a chest x-ray. If the report comes back positive for pneumonia, the pediatrician can file the claim for the office visit with the pneumonia diagnosis (486, Pneumonia, organism unspecified), Linzer says. If the film is normal, code the signs and symptoms diagnoses cough, fever and tachypnea. If pneumonia is diagnosed, that is a definitive diagnosis: Do not also report tachypnea, cough or fever.
 
"The diagnosis of pneumonia can be based on clinical judgment," Linzer says. "X-rays are not 100 percent." Sometimes the pediatrician might diagnose pneumonia based on clinical findings, but the radiologist might miss it on the x-ray.
 
Note: On the radiologist's order, do not write "rule out pneumonia," Linzer says. Use cough, fever and tachypnea as the diagnoses to request the x-ray.
 
Bronchiolitis or respiratory syncytial virus (RSV): In another example, an infant comes in with wheezing (786.07). The pediatrician notes rapid breathing (786.05, Shortness of breath), tachypnea and wheezing, and admits the baby due to a severe RSV epidemic. The pediatrician must choose between the two bronchiolitis codes with RSV (466.11, Acute bronchiolitis due to respiratory syncytial virus [RSV]) or without (466.19, Acute bronchiolitis due to other infectious organisms). Like pneumonia, bronchiolitis is a clinical diagnosis, Linzer says.
 
Without a culture, pediatricians base a bronchiolitis diagnosis on clinical judgment and coding style, Linzer says. For example, if it's winter and RSV is prevalent in the area, some doctors code RSV based on clinical evidence. In July, in areas where RSV is virtually nonexistent in the summer, they would report bronchiolitis only.
 
Many pediatricians use 466.11 whenever there is bronchiolitis. Other pediatricians are more cautious in using an RSV diagnosis. "I would use bronchiolitis unless there is a fluorescent antibody or monoclonal diagnosis of RSV," says Richard A. Molteni, MD, FAAP, medical director of Children's Hospital and Regional Medical Center in Seattle.
 
Fracture or no fracture: In another example, an 11-year-old comes in with a suspected fractured wrist. "You could say clinically that it's fractured, and use a fracture diagnosis," Jacobson says. "But the problem with that is that you would have to change the chart and the claim if the x-ray doesn't show a fracture." Instead, he recommends waiting for the x-ray. If the x-ray shows a fractured wrist, use the appropriate diagnosis from the 813.xx series (Fracture of radius and ulna). If it doesn't, code an injury diagnosis probably 923.10 (Contusion of upper limb; forearm). Do not bill the fracture-repair code (25500, Closed treatment of radial shaft fracture; without manipulation), just an E/M code. When you treat a fracture, the high-paying global fracture-repair codes may be used, Jacobson says. Use fracture repair CPT codes only if there is definitely a fracture; the ICD-9 code will indicate a fracture.
 
Staring or epilepsy: In a fourth example, a child comes in because the parent noticed staring episodes. The pediatrician suspects a possible petit mal seizure disorder (345.2, Epilepsy; petit mal status) but until an EEG or MRI is performed, cannot risk labeling the child with that diagnosis. Instead, report the visit with 780.09 (Alteration of consciousness; other), 781.99 (Other symptoms involving nervous and musculoskeletal symptoms) or 780.02 (Alteration of consciousness; transient alteration of awareness). "Stay away from 345 unless you are positive the child has petit mal epilepsy," Linzer says. If the results of the EEG or MRI come back positive for a seizure disorder, code subsequent visits 345.x.
 
Some pediatricians diagnose seizure disorders clinically. "Let's say you had the child hyperventilate and count to 10," Jacobson says. "And they got as far as five, and stopped counting." That could constitute a clinical basis for petit mal epilepsy, he says. "But if you're really not sure, you can wait for further testing."

Definitive Diagnosis and Symptoms

The best diagnosis code can be elusive when more than one definitive diagnosis exists. The basic rule, according to Linzer, is: If the complaint and symptoms are inherent to the condition, code only the condition; likewise, if diagnosis A is inherent in diagnosis B, report B only.
 
In some cases, two diagnoses would never be used together, because one is inherent in the other. For example, hypertension (403) should not be coded in addition to certain kidney failure codes (585-587) because hypertension always exists in those kidney conditions. Instead of coding the combination, report 403.x1 (Hypertensive renal disease; [malignant, benign, or unspecified]; with renal failure).
 
Dysuria or urinary track infection (UTI): For example, a child has dysuria (788.1) and a fever (780.6). Although a urine specimen is sent for culture, you don't have to wait for the culture to come back positive before using a UTI diagnosis, Linzer says. "You can base a diagnosis of UTI on a screening exam," he says, especially if the child has a fever in addition to dysuria. "If the dipstick comes back positive, use 599.0 (Urinary tract infection, site not specified)," he says. "That code doesn't identify the organism or the site." If you do not have a dipstick-screening test, use dysuria and fever. Use the dysuria and fever codes on the requisition for the culture as well, unless the screening test was positive, in which case report 599.0. Code the fever diagnosis in addition to 599.0.
 
Prematurity and apnea, or intraventricular hemorrhage (IVH): A premature newborn develops apnea (786.03). A head ultrasound is performed, and the scan shows an intraventricular hemorrhage (772.1x). Both diagnosis codes are serious but, clinically, the apnea may be caused by the IVH. "If the apnea is secondary to the IVH, code the IVH first," Molteni says. "Report the apnea too, because it's not inherent in the diagnosis of IVH." List prematurity (765.xx) third.
 
Hypoxia and asthma: Although it is improper to use multiple signs and symptoms codes when there is a definitive diagnosis, sometimes a secondary diagnosis is appropriate and helps justify a higher-level E/M, Jacobson says. For example, a patient with acute asthma (493.0x) comes in. A pulse oximetry is taken, and the reading is 92. Use asthma as the primary diagnosis, and hypoxia (799.0) as the secondary diagnosis. "The payer will look at the hypoxia and see that this was a case requiring extensive work," Jacobson says. "This diagnosis code combination would justify at least a fourth-level E/M service (99204, 99214)." Just as a baby could have apnea without an IVH or an IVH without apnea, a child might have hypoxia without asthma or asthma without hypoxia, so both codes are appropriate on the claim form.

Abdominal Pain

In some cases often with abdominal pain a definitive diagnosis is nonexistent. Abdominal pain, which could be coded only with signs and symptoms (789.0x, Abdominal pain), could end up as appendicitis (540.x), gallbladder disease (575.x), or another serious problem. Arrive at a specific definitive diagnosis whenever possible, and code all signs and symptoms when not possible.
 
"If the patient has vomiting, diarrhea and abdominal pain, you can code acute gastroenteritis (558.9)," Linzer says. Do not report vomiting, diarrhea and abdominal pain, because these symptoms are inherent to gastroenteritis.
 
Abdominal pain can also be caused by strep throat. For example, a patient has a headache (784.0), a sore throat (462), and abdominal pain (789.0x). Use all three codes for the visit and for the requisition for the throat swab culture sent to the lab. If a positive strep screen is performed in the office, report only the strep throat (034.0).
 
Because abdominal pain can signal appendicitis, this diagnosis alone although only a sign/symptom often requires extensive physician work, Jacobson says. "The patient could die if you don't pick up appendicitis," he says. "So I frequently use abdominal pain for possible appendicitis because we can't use rule-outs." A diagnosis of appendicitis isn't made until surgery. Bill the visit based on the symptom.