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.
Definitive Diagnosis
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.
Waiting for Test Results
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 [...]