Primary Care Coding Alert

Question: A mother brought her child to our office because her sixmonth-old child was "acting sick" by screaming constantly.

The only symptoms the doctor charted were runny nose and constant screaming. He told me to code the diagnosis as "worried well check," but I'm not sure. What's the best option? Texas Subscriber

Answer: Code according to the documented symptoms, not just by your physician's undocumented comment. Appropriate symptoms in this situation could include 784.99 (Other symptoms involving head and neck) for the runny nose or 780.91 (Fussy infant [baby]) or 780.92 (Excessive crying of infant [baby]) for screaming. You normally report V65.5 (Person with feared complaint in whom no diagnosis was made) when a patient doesn't have a problem but wants to be checked and reassured. You have other symptoms that would serve as better diagnoses.