Pediatric Coding Alert

A guide to reporting possible and obvious trauma cases E/M and ICD9 Codes for child-abuse exams don't have to be uncharted water if you're following this rule of thumb: Report a mid- to high-level office visit and an observation, injury, sign, symptom or abuse code. 
 
Sometimes the abuse is obvious. Other times, a parent suspects abuse when none is found. Handling these difficult situations can prove emotionally trying without having to worry about the coding. 
 
To guide you through various reporting challenges, experts suggest strategies for coding the following four typical scenarios: 1. Parent Suspects Abuse, But None Found For treating a possible abuse case with no findings, you may code the E/M based on time and use a diagnosis code that reflects the negative results.
 
A common scenario is the parent who shows up in your office on Monday morning after the child spent the weekend with the noncustodial parent, says Jeffrey Linzer Sr., MD, FAAP, assistant professor of pediatrics for the division of emergency medicine at Emory University School of Medicine in Atlanta. The mother says, "I just want to see if my son was abused." The pediatrician asks the child if anyone touched him inappropriately over the weekend and if anyone hurt him. The boy answers "No" to the questions. Upon examination, the pediatrician finds nothing - no signs of abuse whatsoever.
 
In this situation, the level of E/M code that you select will depend on the amount of time the physician spent talking to the child and the depth of the exam, Linzer says. While at a minimum, you could report 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...) for an expanded problemfocused history and exam, this type of suspected abuse would likely lead to a detailed history and exam and meet the requirements for moderate-complexity medical decision-making (99214). The time the pediatrician spent counseling and coordinating care could become the key component justifying 99215.
 
The visit may easily qualify as a level-five visit based solely on counseling time and coordination of care, says Victoria S. Jackson, the administrator and chief executive officer of Southern Orange County Pediatric Association in Lake Forest, Calif. Because counseling will likely dominate the E/M service, you may use time as the key element when determining the appropriate outpatient office visit level (99212-99215), she adds.
 
For an exam that results in no abuse findings, you should report V71.81 (Observation and evaluation for other specified suspected conditions; abuse and neglect) as a principle diagnosis, says Linzer, who is the American Academy of Pediatrics representative to the [...]