Pediatric Coding Alert

The common complaint of abdominal pain can result in many potential diagnoses, and may lead to a hospital observation stay or even surgery. The following case study examines three coding scenarios related to abdominal pain and how to code each successfully.

Scenario 1: Office Visit Only

An established, 13-year-old female patient arrives at the pediatricians office. She has had midabdominal pain for 12 hours, with one episode of vomiting during that time. There is no diarrhea, fever or dysuria, and her last menstrual period occurred two weeks ago. On physical examination the patient appears well-hydrated with moderate abdominal pain on deep palpation, but no rebound tenderness. The results of a urinalysis (81000, urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, with microscopy) are normal. The physician arrives at a differential diagnosis of gastroenteritis, midcycle ovulatory pain, mesenteric adenitis or a developing surgical abdominal problem such as early appendicitis.

This office visit is CPT 99213 , says Richard H. Tuck, MD, FAAP, a member of the American Academy of Pediatrics Coding and Reimbursement Committee and a practicing pediatrician in Zanesville, Ohio. The history is expanded problem-focused, with a problem-pertinent system review, and the examination is expanded problem-focused with a limited examination of the affected body area and other related organ systems. Medical decision-making qualifies as moderately complex there are multiple diagnoses, a moderate amount of data and a moderate risk of complications. Potential gynecological concerns complicate the medical decision-making, Tuck explains. You also need information about the family history of gastrointestinal problems.

The office visit should be linked to diagnosis code 789.07 (abdominal pain, generalized).

The level of the visit may rise to 99214 if a detailed history including a past, family or social history of the gastrointestinal problem as well as an extended history of the problem and a review of additional systems beyond the gastrointestinal system, are medically necessary and properly documented. Similarly, if the child exhibits a coincidental respiratory illness with cough or fever (pneumonia can mimic appendicitis), the visit might qualify as a 99214, says Tuck. A detailed examination (involving another related organ system) might also raise the level of evaluation and management (E/M).

If the pediatrician performs an x-ray in the office as part of the examination, code 74000 (radiologic examination, abdomen; single anteroposterior view) in addition to the E/M service.

Scenario 2: Observation

Later that evening the patients condition worsens, and the pediatrician meets her at the hospital emergency department.

The abdominal pain has moved to the right lower quadrant, and the patient is experiencing persistent nausea and vomiting, has had one loose stool and her temperature has risen to 101. The pediatrician admits the patient to observation and orders a urinalysis, complete blood count (85023) and sedimentation rate (85651). The girl is made NPO (nil per os, i.e., nothing by mouth). The physician prescribes intravenous fluids and orders x-rays and possibly an abdominal ultrasound.

Coding for observation services (99218-99220) requires that all three components (history, examination, and medical decision-making) of an E/M service are met to justify a given level. Because hospital observation services (99218-99220) are per-day codes, the pediatrician cannot bill the earlier office visit in addition to the observation code, but he or she may incorporate the work performed in the office into the observation code. In this case, the history and examination are detailed, but medical decision-making is still moderate. Without incorporating the earlier office visit into the observation services, the pediatrician would probably code 99218. The additional work performed during the office visit can be accounted for by coding 99219 for the observation status. To code 99220 in this situation, there would have to be other problems going on in addition to abdominal pain, such as a high fever or serious dehydration, says Susan Callaway, CPC, CCS-P, an independent coding auditor based in North Augusta, S.C.

The corresponding diagnosis is 789.03 (abdominal pain, right lower quandrant).

Note: The hospital does not need a special area set aside for observation for the provider to bill observation care codes. The codes refer to the status of the patient, not the place of service.

Scenario 2, Continued: Observation to Discharge

The pediatrician re-examines the patient the next morning. She is improved with only minimal right lower quadrant abdominal pain. The examination reveals no significant tenderness and no rebound. The physician prescribes a milk-free diet and advances her to clear fluids. The patient improves throughout the day and is discharged that evening.

Code 99217 (observation care discharge day management) should be used because the patient was discharged on a different date from the admission to observation. This per-day code includes the examination, instructions for care and preparation of discharge records. The discharge diagnosis is gastroenteritis (558.9).

Scenario 3: Observation to Surgery to Discharge

The pediatrician examines the patient on the morning following admission to observation. The patient exhibits rebound tenderness in the right lower quadrant with decreased bowel sounds. She is admitted to the hospital with a pediatric surgical consultation. The consultant takes the patient to the operating room where an inflamed appendix is removed. The patient recovers uneventfully and is discharged the following day. Throughout the stay, however, the pediatrician continues to follow the patient for fluid management and family support.

The pediatrician would code a hospital admission (99221-99223). Subsequent hospital care codes require two of three key components to meet the criteria for a given level of E/M service. Based on the level of medical decision-making, this visit would probably qualify as a 99221 or 99222, Callaway says. The pediatrician would not code an observation code on this date.

Do not use the subsequent hospital day codes (99231-99233). CPT specifies, For a patient admitted to the hospital on a date subsequent to the date of observation status, the hospital admission would be reported with the appropriate inpatient hospital care codes (99221-99223). Nor should the pediatrician bill a discharge (99217) on the day the patient is admitted from observation.

Co-management Issues

Although the surgeons hospital visits on days after the surgery (as well as the patient discharge) are included in the global fee for the appendectomy, the pediatrician can bill for subsequent hospital days using 99231-99233 provided he or she is managing a condition other than the appendicitis, such as dehydration. The pediatrician must also use a diagnosis other than that which led to the surgery. For example, for dehydration, he or she should link diagnosis code 276.5 (volume depletion) to the appropriate-level subsequent care code.

If no condition requires the pediatricians management, he or she will release the care of the patient to the surgeon. Although the pediatrician will probably stop in to say hello when doing rounds, this is classified a social visit and is not billable. Sometimes, however, the parents and child are uncomfortable with the surgeon and insist on speaking with the pediatrician about their concerns. The pediatrician may bill this time as a consultation (99251-99263), but only if he or she is helping the family with medical issues, such as abdominal pain or IV management, and the other criteria for a consultation are met. The non-coding solution is to request that the parents ask the surgeon any questions they have. I tell the parents to make a list of their concerns, Tuck says. They can bring out that list when the surgeon comes in.

Pediatricians must accept, however, that in general they are communicators, and surgeons often arent. That means pediatricians get the questions, and cant always bill for giving the answers.