Pediatric Coding Alert

Question: A mother came to us with her daughter, who had just started daycare. For two days, the patient had experienced diarrhea, fever, and vomiting. Our pediatrician also noted that she was dehydrated and that her stomach was distended and tender when palpitated. After administering a test, our provider diagnosed the patient with rotavirus. How should we go about documenting this encounter, and what can we expect moving forward?

Ohio Subscriber

Answer: Your first step in this scenario is to code the patient's symptoms, which would be

• R19.7 - Diarrhea, unspecified
• R50.9 - Fever, unspecified
• R11.11 - Vomiting without nausea
• E86.0 - Dehydration
• R10.817 - Generalized abdominal tenderness

However, in order to arrive at a definitive diagnosis of A08.0 (Rotaviral enteritis), your provider would have to administer 86759 (Antibody; rotavirus), which is an immunoassay test that evaluates the patient's serum for antibodies to rotavirus.

From there, your pediatrician will probably recommend either 90680 (Rotavirus vaccine, pentavalent (RV5), 3 dose schedule, live, for oral use) or 90681 (Rotavirus vaccine, human, attenuated (RV1), 2 dose schedule, live, for oral use). These vaccinations are currently required in Idaho, Louisiana, Ohio, and Rhode Island (source: http://www.immunize.org/laws/rotavirus.asp), although the Centers for Disease Control (CDC) highly recommends them regardless of where you live (source: https://www.cdc.gov/vaccines/schedules/easy-to-read/child-easyread.html).

Finally, you need to conclude your reporting by choosing the most appropriate code from the Z28- (Immunization not carried out and underimmunization status) sequence. If the child has not received the vaccination for medical reasons, you would choose a code from Z28.0- (Immunization not carried out because of contraindication), for example, while Z28.82 (Immunization not carried out because of caregiver refusal) would indicate that the parent had refused the child's vaccination on religious or philosophical grounds.