Pediatric Coding Alert

Signs and symptoms or V code may be your key in these situations

If you can't confirm child abuse, use a diagnosis code that reflects the negative results, coding experts say.

Scenario 1: A parent arrives in your office on Monday morning after the child spent the weekend with the noncustodial parent. She suspects her son was abused. When the pediatrician asks the child if anyone hurt him, he responds "No" to each of the questions. Upon examination, the physician finds no signs of abuse.

Diagnosis Solution 1: 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). You should link the code to the E/M visit (for example, 99213, Office or other outpatient visit for the evaluation and management of an established patient ...).

Scenario 2: A mother brings in her 7-year-old son for behavior problems. She maintains that the child will not obey, even though she frequently puts him in time out and takes away privileges. Upon examination, the pediatrician notices that the boy is quite thin and malnourished. He also has several welts from possible previous beatings.

Diagnosis Solution 2: If the physician is not sure the child's condition is caused by emotional/psychological abuse (995.51) and neglect (995.52), you may report the signs and symptoms, such as underweight (783.22), malnourishment (263.9) and/or contusions (for example, 922.3x, Contusion of trunk; back).

Nonetheless, the pediatrician has a legal and ethical obligation to report suspected abuse.