Pediatric Coding Alert

Remember that V20.2 isn’t your only well-visit option.

You see it at least once a day: The worried parent, especially the new one, who wants to bring the baby in just to make sure everything is okay. Maybe it’s a six-month-old whose mother thinks is teething, or perhaps it’s a one-year-old who is cranky and maybe he has an ear infection that they’d like you to simply check. Even older kids come in with potential sprains or fractures, but you see the child, and in fact, nothing is wrong. How do you bill for these visits?

The answer is to bill for the symptoms, since you can’t bill for parental anxiety, as well as adding the appropriate “V” code to denote the well visit.

Worried Well Coding

There are two diagnosis codes that might seem appropriate for these cases: V65.5 (Person with feared complaint in whom no diagnosis was made) and V71.9 (Observation for unspecified suspected condition).

Also known as worried well, V65.5 is an excellent code for pediatrics. Worried well is not associated with hypochondria or psychological illness, but is instead perfect for those instances when a parent fears the patient has a problem but the visit results in no diagnosis. The following two examples illustrate the use of this code.

1. Just to make sure. A mother brings her child who recently got over a cold to the pediatrician prior to a cross country trip to see grandmother, “Just because I want to make sure everything is OK,” the mother tells you. There are no signs, symptoms or problems. This is a perfect place to use V65.5 all by itself because there is no other problem present. The parent may have to pay for this visit as insurance will often (but not always) deny payment for this diagnosis code. Here, no specific feared condition is present, making V65.5 your best bet.

2. Pulling at ears. The mother brings in an infant saying that the baby has been pulling at the ears. On exam, the child has no fever and the ears look fine. The child is well, but you need to spend extra effort to determine this, warranting a 99213 (Office or other outpatient visit for the evaluation and management of an established patient). To support the E/M code, you should use V65.5 as the secondary diagnosis, along with otalgia (388.71) as the primary diagnosis.

It is very important to push to find out what the parents are worried about. Get them to be as specific as possible about the illness they are afraid the child has so you can code that suspected diagnosis first and V65.5 second. While this would seem to be contradictory (V65.5 is specifically for when no diagnosis is made), this is what tips off the insurance company that there was a specific concern.

Code V71.9 (Observation for unspecified suspected condition) is not appropriate when there are any symptoms or signs at all. It is defined as a category to be used when patients without a diagnosis are suspected of having an abnormal condition, without signs or symptoms, which requires study, but after examination and observation, is found not to exist.

Many pediatricians attribute non-specific crying in very young infants to colic (789.0). They use the diagnosis code for the symptom as the primary diagnosis, followed by V71.8 (Observation and evaluation for other specified suspected conditions), which is for ruling out a specified suspected condition, to show that the diagnosis actually is not present. Fortunately, pediatricians don’t typically have a hard time getting reimbursed for these visits in newborns.