Pediatric Coding Alert

Question: Our pediatrician saw a 4-year-old whose mother said had been acting like he doesn’t feel well but she can’t find anything wrong. After examination, the pediatrician agrees and records no diagnosis, signs, or symptoms. Is there a Z code I could report?

New Jersey Subscriber

Answer: For encounters that conclude without a diagnosis, or with no signs, or symptoms, you can use either Z03.89 (Encounter for observation for other suspected diseases and conditions ruled out) or Z71.1 (Person with feared health complaint in whom no diagnosis is made). However, reporting Z03.89 is likely the best option in this scenario. Here’s why.

Codes from the Z03 category are for situations “when a person without a diagnosis is suspected of having an abnormal condition, without signs or symptoms, which requires study, but after examination and observation, is ruled out,” according to ICD-10 guidelines under the category. In other words, you can report these codes when the pediatrician suspects the patient might have a condition that requires treatment but then rules out the condition after examination. If you look further down to the Excludes1 note, you’ll see mention of Z71.1, which is a clue that these two codes are not interchangeable.

Under 271.1, ICD-10 includes “worried well” encounters, which is a layperson term for when a person presents with fear of illness but demonstrates no signs of the illness. The examination in these situations is to reassure and essentially reduce patient or caregiver anxiety.

To select the correct code, compare the language in the documentation with the language in the code and category descriptors. Unless the notes expresses significant fear or worry on the part of the patient or parent, you probably would not submit Z71.1. The pediatric patient complained of feeling ill, the parent couldn’t easily identify anything physically wrong, and therefore sought a professional medical opinion. Upon full examination the pediatrician determined there was no illness to report. Consequently, reporting Z03.89 would probably represent the encounter more accurately.