Pediatric Coding Alert

5 scenarios walk you through using V20.2 versus a problem dx

Not sure which diagnosis to use for hyperbilirubinemia checks with no problem found? Code V20.2 may be your answer.

Pediatricians have long struggled with the ICD-9 code to use for post-birth visits to check the baby's bilirubin level. The American Academy of Pediatrics (AAP) recommends that physicians examine most infants the first few days after discharge to assess the infant's well-being and the presence or absence of jaundice. But a specific ICD-9 code recommendation did not accompany the policy, leaving coders wondering which diagnoses apply, says Victoria S. Jackson, practice management consultant with JCM Inc. in California

In fact, the academy did hear your requests. The AAP asked for an ICD-9 code for a hyperbilirubin check in which no problem was found, says Jeffrey F. Linzer Sr., MD, FAAP, FACEP, associate medical director for compliance and business affairs at EPG in Egleston, Ga. But CMS said no.

Instead: ICD-9 2007 added the notation "Initial and subsequent routine newborn check" following V20.2 (Routine infant or child health check) that indicated these encounters may fall under V20.2. You should still use another ICD-9 code when the infant has a problem or when the pediatrician suspects a problem at discharge that prompts the office encounter. These five examples walk you through the art of coding visits involving bilirubin checks.

Code Normal Visit as V20.2 Well Check

When the baby has no problem and the pediatrician performs and documents all components of the health check, you'll match V20.2 with the child's first well check code. "You may count a first bilirubin check in which no problem is found as the initial preventive medicine service," says Richard Tuck, MD, FAAP, a pediatrician at PrimeCare of Southeastern Ohio. After finding an infant healthy and normal, the pediatrician would continue to provide the rest of the services associated with the first well check visit.

Example 1: An experienced mother brings in a formula-fed infant who was discharged less than 48 hours after birth to see how the baby has transitioned to home life. The mother has no complaints at the visit. A nurse checks the baby's weight and finds no weight loss. The pediatrician asks questions about the baby's feeding and examines the newborn for signs of jaundice. He finds no current problems and performs and documents an age-appropriate history and examination including a phenylketonuria (PKU) screen.

Solution: Because the pediatrician does not find or treat any problems at this visit and instead performs the services associated with an initial preventive medicine service, you should report V20.2 and 99391 (Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination ...; infant [age younger than 1 year]). If the pediatrician's office performs the screen, report 84030 with a diagnosis of V77.3 (Special screening for endocrine, nutritional, metabolic, and immunity disorders; phenylketonuria [PKU]).

For the heel stick, assign 36416 (Collection of capillary blood specimen [e.g., finger, heel, ear stick]).

Consider V Code for Suspected Conditions

For visits that focus on a suspected problem that seems to be resolved, switch to a sick visit and a V code.  When a pediatrician sees a newborn for the purpose of evaluating for hyperbilirubinemia, dehydration or feeding problems who now appears to be a normal newborn without problems, use V29.x (Observation and evaluation of newborns and infants for suspected condition not found), says the Georgia Chapter of the AAP in its tips on Coding for Newborn Visits.

Example 2: A breast-fed infant of a new mother loses significant weight in the hospital and has few wet diapers. The pediatrician's discharge orders include recommending that the mother schedule an office appointment in two to three days to check weight, assess for hyperbilirubinemia and nursing progress. At the visit, a nurse checks the infant's vitals and weight. A pediatrician performs the history and examination, during which he finds the infant has returned to his birth weight, is breastfeeding well, is stooling and voiding normally. There is no sign of jaundice.

Do this: Report the problem-focused encounter with an office visit code (99212-99215, Office or other outpatient visit for the evaluation and management of an established patient ...) and V29.x. You can't use ICD-9 codes for weight loss (783.21) or feeding problems (779.3, Feeding problems, newborn), because the newborn no longer has that problem.

Use V58.89 and 774.6 When Jaundice Is Resolved

You can use a secondary diagnosis of jaundice when the pediatrician diagnosed the newborn with the condition in the hospital and ordered the office visit for another bilirubin level.

Example 3: At an office encounter for follow-up of a newborn with jaundice in the hospital, the pediatrician finds no signs of jaundice, and a transcutaneous test confirms a normal bilirubin level. To indicate jaundice resolved, you may report "V58.89 (Other specified aftercare) and, if allowed by the third- party payer, 774.6 (Unspecified fetal and neonatal jaundice) as secondary," instructs the Georgia AAP. Some insurers may not allow the V code as a primary diagnosis, necessitating reporting the diagnoses in the reverse order.

Don't forget to code for the transcutaneous bilirubin check with 88400 (Bilirubin, total, transcutaneous). If staff obtains a blood specimen for the bilirubin level, report the heel stick with 36416 and an in-office bilirubin test with 82247 (Bilirubin; total).

Report Problem With 9921x, Problem Dx

If, however, the pediatrician finds the newborn has a problem, you should report the definitive diagnosis.

Example 4: A post-discharge encounter shows an infant has lost weight. The pediatrician's visit focuses on the mother's breastfeeding, including observing latching on and breastfeeding, educating the new mom on hunger signs, initiating a forced feeding schedule and an order to return in two days for another weight check.

Answer: Because the pediatrician performs a problem-focused examination related to the infant's weight loss and feeding problems, you should code a problem-related visit, such as 99213-99214, and use the problem as the diagnosis, 783.21 for weight loss and 779.3 for feeding problems.

Use 774.6 When Jaundice Is Diagnosed

Similarly, you should code a problem-related visit and the problem diagnosis when the pediatrician finds that an infant has jaundice.

Example 5: A new mother presents for an office visit two days after hospital release with a breastfed infant. The child's skin is yellow, and she sleeps excessively. The pediatrician diagnoses the infant with hyperbilirubinemia and recommends increasing feedings and discusses the jaundice diagnosis and treatment options.

Because this visit focuses on the problem of hyperbilirubinemia, you should use the appropriate-level office visit code, such as 99213-99214, with the definitive diagnosis of jaundice (774.6, Unspecified fetal and neonatal jaundice).