Pediatric Coding Alert

While it's highly unlikely that you will have a case of anthrax in your office, you have been told to be on the alert. You are more likely to see anxious parents who want to ask about anthrax and find out how to protect their children. You may even have cases of possible exposure that require antibiotics. Some basic coding tips can help pediatricians navigate this uncharted territory.

You must select a diagnosis code, the key to payment for the E/M visit, based on (a) whether the child was exposed to anthrax and (b) whether the child has symptoms.
 
1. Negative exposure, negative symptoms. The child who has no possible exposure and no symptoms has no need for treatment. In one scenario the mother is near hysteria and wants you to confirm that her child "doesn't have anthrax." Probe as to why she thinks the child might have anthrax. Was he or she in a contaminated building? Does he or she have an odd skin lesion or flu symptoms? A "yes" answer will lead to a useful diagnosis code.
 
If the mother insists that the child has no exposure or symptoms, code V65.5 (other persons seeking consultation without complaint or sickness; person with feared complaint in whom no diagnosis was made), says Tom Kent, CPC, CMM, president of Kent Medical Management, Dunkirk, Md. The "worried well" diagnosis code will probably not be paid by the family's insurance plan. Regardless of what you do during this visit you may spend 15 minutes talking to the mother about anthrax, for example you should use the worried well diagnosis code.
 
If you are very uncomfortable about coding "worried well," use V71.9 (observation and evaluation for suspected conditions not found; observation for unspecified suspected condition), recommends Jeffrey Linzer, MD, FAAP, AAP representative to the ICD-9 editorial advisory board.
 
2. Negative exposure, positive symptoms. If the child has symptoms not necessarily of anthrax, which is difficult to diagnose in the early stages, but of anything code the symptoms, Linzer says. Possible symptoms include upper-respiratory infection (465.x, acute upper respiratory infections of multiple or unspecified sites; 487.1, influenza; with other respiratory manifestations), skin bump (782.2, symptoms involving skin and other integumentary tissue; localized superficial swelling, mass, or lump) or cough (786.2, symptoms involving respiratory system and other chest symptoms; cough).
 
You may even have enough information to be sure the diagnosis is flu; code 487.1 in the primary slot and the symptom (786.2 for cough) in the secondary slot.
 
3. Possible exposure, negative symptoms. If the child has no symptoms but has been exposed to anthrax, do not use V65.5 (worried well). Instead, use V01.8 (contact with or exposure to communicable diseases; other communicable diseases) as the primary diagnosis code, Kent says. Do not use the anthrax codes (022.x) unless you have a confirmed diagnosis.
 
If you treat with antibiotics, use V07.39 (need for isolation and other prophylactic measures; other prophylactic chemotherapy), CMS recommends in an Oct. 26 memorandum to Medicare contractors.
 
Note: This CMS memo is for Medicare patients; private payers may have different coding rules for anthrax prophylaxis and testing.
 
4. Possible exposure, positive (but not necessarily anthrax) symptoms. In this case, the child has been exposed to anthrax and has symptoms that could be a cough, bug bite or flu and not anthrax at all or could be. Pending a culture, you can only code the symptoms. List the signs and symptoms code first and the exposure code (V01.8) second. Again, if you treat with antibiotics, code V07.39.
 
If you are not sure if the child has been exposed to anthrax and perform a nasal swab test, code V71.9 in the primary position and V74.8 (special screening examination for bacterial and spirochetal diseases; other specified bacterial and spirochetal diseases) in the secondary position, Linzer says.
 
5. Positive nasal swab. If you treat a child with antibiotics who has a positive nasal swab for anthrax, submit claims with 795.3 (nonspecific abnormal histological and immunological findings; nonspecific positive culture findings).
 
"Because the nasal swab test is not conclusive for disease, you should not use an anthrax diagnosis code," explains Charles Schulte, MD, FAAP, chairman of the AAP committee on coding and reimbursement. A positive nasal swab can imply that the patient has had positive contact, but not the disease. That is why you should code the nonspecific positive culture finding. "A positive nasal swab is not necessarily the disease," Schulte explains. "The child would have to be sick with anthrax to have an anthrax diagnosis."
 
Schulte recommends also using E997.1 (injury due to war operations by other forms of unconventional warfare; biological warfare) for the patient with a positive nasal swab. However, Kent warns that this code should be reserved for an outbreak that the government specifically labels as biowarfare. Most life, disability and health-insurance coverages specifically exclude injuries that occur as part of a war action. Using this code could cause an insurer to deny coverage, Kent says.
 
6. Positive diagnosis. Use the anthrax diagnosis only when the patient is confirmed to have a condition caused by anthrax bacillus. Use the specific code: 022.0 (cutaneous anthrax), 022.1 (pulmonary anthrax), 022.2 (gastrointestinal anthrax), 022.3 (anthrax septicemia), 022.8 (other specified manifestations of anthrax) or 022.9 (anthrax, unspecified).

Code the procedure for a patient concerned about or exposed to anthrax with an outpatient E/M services code (99201-99215). Most of the patients who come to you with anthrax concerns are probably established patients (99212-99215), so you only need to satisfy two out of three criteria for selection of a level. You will perform at least a detailed examination on these patients. The medical decision-making will be crucial to determine the E/M level.
 
On one end of the spectrum is the child with no symptoms and no exposure. You would probably not code a high-level E/M particularly if you are using a "worried-well" diagnosis code. If more than 50 percent of the encounter time is spent on counseling, you can code based on time.
 
On the other end of the spectrum is the child who has been exposed, and you must prescribe antibiotics. The two top antibiotics for anthrax are not recommended for young children, although pediatricians give them when the benefits outweigh the risks. For example, ciprofloxacin can cause a broad range of growth problems in children; doxycycline can cause gray teeth in young children while adult teeth are forming. Prescribing a medication is a risk indicator that can justify a higher-level E/M code; prescribing these medications would qualify.
 
Nasal swab testing would be filed by the laboratory with 87081 (culture, presumptive, pathogenic organisms, screening only). Link V01.8 to the pathology code if the patient "has had contact with or exposure to a communicable disease or biological agent," whether or not the patient has signs or symptoms of the disease, according to the CMS directive.
 
Collection of the specimen is included in the E/M; the pediatrician would not bill for it.
 
For clinical information on anthrax, visit www.aap.org/advocacy/releases/anthraxsusp.htm, or www.bt.cdc.gov/DocumentsApp/Anthrax/11072001/clinician.asp.