Pediatric Coding Alert

Question: Our pediatrician evaluated a 9-month-old established patient whose parent reported three days of cough, rhinorrhea, nasal congestion, and low-grade fever, with worsening breathing difficulty the morning of the appointment. The infant had been lethargic and eating less than usual. Examination revealed tachypnea, respiratory distress, wheezing, crackles, and low oxygen saturation. An in-office respiratory syncytial virus (RSV) test was positive, and the pediatrician diagnosed acute RSV bronchiolitis. The physician documented the discussion with the parent regarding the possibility of hospitalization, noting the infant was borderline for admission. Following shared decision making, they decide on close home monitoring with a follow-up visit the next day. The pediatrician recommended acetaminophen as needed and reviewed proper nasal suctioning techniques with the parent for symptom relief.

How should I code this encounter?

AAPC Forum Participant

Answer: Because the RSV test was positive, you’ll assign J21.0 (Acute bronchiolitis due to RSV). Physicians often diagnose bronchiolitis based on the patient’s clinical presentation alone. In cases where the provider can identify no specific viral cause, you’ll report J21.9 (Acute bronchiolitis, unspecified). This code is also appropriate when RSV testing is negative.

For the lethargy, difficulty breathing, and low oxygen (hypoxia), you’ll assign R09.02 (Hypoxemia). Hypoxia should be added as a second diagnosis code.

E/M selection: The risk element may hinge on whether the pediatrician documented consideration of hospital admission due to the infant’s low oxygen saturation. In situations like this, the decision to hospitalize often depends on the severity of the hypoxia and the comfort level of both the physician and family with continued observation at home despite the potential for clinical deterioration. Because possible hospitalization was discussed and documented, the risk element supports a high level.

The most appropriate evaluation and management (E/M) code for this visit is 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.) This choice reflects the moderate complexity, limited data, and high risk of the patient’s situation.

Make note: To bill for the RSV test itself, you must know which type of point-of-care RSV test the office used. Most offices will use 87634 (Infectious agent detection by nucleic acid (DNA or RNA); respiratory syncytial virus, amplified probe technique). However, some offices will use 87807 (Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; respiratory syncytial virus).

Lindsey Bush, BA, MA, CPC, Production Editor, AAPC