Primary Care Coding Alert

Submit thorough documentation to prevent payer pushback.

Primary care practitioners (PCPs) see patients with a variety of problems. They must be ready for anything the patient brings to the encounter, even if what they bring is, well, nothing. It’s not at all uncommon for an encounter to result in the patient not having any discernible problem. So how do you code these kinds of encounters?

Here are three common questions related to this very scenario along with answers provided by our experts.

Question 1: What if our PCP sees an infant whose mother suspects illness, but the child isn’t actually ill? How do I report the encounter without a diagnosis?

Answer: This is a common scenario for physicians who see children. Just because there is no formal diagnosis doesn’t mean there’s nothing to report. Fortunately, ICD-10 guidelines point to a combination of codes that will help you paint an accurate picture of the encounter.

Section I.B.4 is the place to start, “which says ‘codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider,’” says Donna Walaszek, CCS-P, billing manager, credentialing/coding specialist for Northampton Area Pediatrics, LLP, in Northampton, Massachusetts.

The guidelines go on to clarify that “while specific diagnosis codes should be reported when they are supported by the available medical record documentation and clinical knowledge of the patient’s health condition, there are instances when signs/ symptoms codes are the best choices for accurately reflecting the healthcare encounter,” per guideline I.B.18.

Symptom coding: Let’s say a mother brings in her infant and tells the PCP the child has been fussy and has been rubbing his eyes a lot. The mother suspects an infection of some kind such as pink eye, but when the practitioner examines the child, they determine the child is not running a fever and finds no problems with the eyes.

In this situation, the mother brought the child in because she observed the child was acting more fussy than usual. So, therefore “R68.12 [Fussy infant (baby)] is — and should be considered — a sign/symptom for the encounter and is the best choice for accurately reflecting the healthcare encounter given the lack of a definitive diagnosis,” Walaszek advises.

Note, also, that while the mother observed the child rubbing his eyes more than usual, there was no observable indication of pain, and the physician reported no redness, discharge, irritation, or any other sign that there was something wrong with the child’s eyes. This means that R68.12 is the only symptom code to report.

Z-code: Submitting Z71.1 (Person with feared health complaint in whom no diagnosis is made) alongside the symptom code will likely help support the claim also. The Z71 codes are used for “persons encountering health services for other counseling and medical advice, not elsewhere classified,” according to ICD-10 guidelines. Under Z71.1, ICD-10 includes “worried well” encounters, which is a lay term for when a person presents with fear of illness but demonstrates no evidence of the illness. The examination in these situations is to reassure and essentially reduce patient or caregiver anxiety.

Coding alert: In researching Z71.1, you may come across observation code family Z03.8- (Encounter for observation for other suspected diseases and conditions ruled out). While the descriptor makes this code a tempting choice, it will not work in this scenario. According to ICD-10 guideline I.C.21.c.6., observation codes are “not for use if an injury or illness or any signs or symptoms related to the suspected condition are present. In such cases the diagnosis/ symptom code is used….”

Question 2: How do I report the E/M when most payers want a diagnosis?

Answer: Even though the PCP did not formally diagnose the patient with anything, they did perform an evaluation and management (E/M) service. The trick is to accurately report it, so that the practitioner is fairly reimbursed for the work they did. Remember guideline I.B.18, too, which states that the symptom code can be used in lieu of a formal diagnosis.

Code for Time: When you’re dealing with infants and small children, who can’t clearly communicate and exhibit vague symptoms, that encounter “often requires more of a history and exam to determine what is wrong with the patient,” advises JoAnne M. Wolf, RHIT, CPC, CEMC, AAPC Fellow, coding manager at Children’s Health Network in Minneapolis.

“This is not an uncommon scenario. Assuming the encounter documentation supports it, I would consider selecting an E/M level based on time,” suggests Jan Blanchard, CPC, CPEDC, CPMA, of Physician’s Computer Company in Winooski, Vermont. This way, you aren’t shackled to an inappropriately low-level E/M level based on medical decision making (MDM) when there is seemingly no problem, and the PCP has not ordered or analyzed a test for the encounter.

For a child already established to the practice, then, your code choices based on time would likely include 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 10-19 minutes of total time is spent on the date of the encounter.) or possibly 99213 (… 20-29 minutes of total time …), given the nature of the patient’s presenting problem.

Question 3: What’s the best way to avoid a denial when reporting an encounter with no illness or diagnosis?

Answer: Thorough documentation is the key to avoiding all sorts of problems, especially in scenarios such as this one where there is so much room for potential payer pushback. If the physician has documented the encounter and reasonably accounted for the time spent, the claim should end in proper payment.

In the end, “it is definitely good business practice to bill for all services rendered. Just because a child is not ill does not mean that it did not require your physician’s expertise, based on years of expensive training, to determine that something serious is not going on. Payers will push back on everything that they can, but if you have documented care well enough to defend the claims, you must report them,” cautions Blanchard.