Pediatric Coding Alert

Question: If a child comes in several times within a two- to three-week period, how should we code if some of the visits are for different symptoms and have nothing to do with previous visits?

Nevada Subscriber

Answer: For each date of service, use the diagnosis codes for the most significant illness treated on that day. If previous problems have a medical decision-making impact on that service, the documentation may justify a higher level of office visit.

For example, a child presents with an upper respiratory infection (465.x) on the initial visit. The next week, the child has developed a fever, and you find otitis media (381.xx). Several days later, the parent notices wheezing after the child has been playing outside, and upon examination you order a nebulizer treatment for an asthma attack (493.xx). Code each encounter with the principal diagnosis for that specific visit.