Primary Care Coding Alert

Question: We recently had a mother bring in her 4-year-old son because she was concerned about the childs inability to potty train. The doctor conducted a urinalysis and checked the child for any physical conditions that might be affecting elimination. All these findings were negative. The doctor counseled the mother about toilet training and noted, delayed potty training in his notes. Which diagnosis code would I assign?

Pennsylvania Subscriber

Answer: Unless the child presents with symptoms indicating signs or symptoms of a urinary condition (e.g., 599.0, urinary tract infection, site not specified), the best code to assign is 783.40 (lack of normal physiological development, unspecified) or 783.42 (delayed milestones). Because this is not clearly defined, coders should check with the payer in question and confirm which code they will accept.

The visit itself is coded with the appropriate office or other outpatient visit code (99201-99205, new patient; 99212-99215, established patient), depending on the level of the exam and history, and the complexity of the medical decision-making. In addition, coders may report the urinalysis with code 81000 (urinalysis, by dip stick or table reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, with microscopy).