Pediatric Coding Alert

Pediatricians shouldnt rely on the billing department to choose procedure (CPT Codes ) and diagnosis (ICD-9) codes. Only the physician can determine the proper diagnosis and document the encounter. And, ultimately, auditors will hold the doctor, not the office staff, responsible for proper coding.

The coding department at the office that does our billing wont assume anything, says Sheryl Cilento, office manager for Liberty Child and Adolescent Health Services, a 12-pediatrician practice within Jersey City Medical Center in Jersey City, N.J., where billing is outsourced. If theres a question, they come back to us right away to get it fixed before sending it in.

The kinds of questions range from What is the fifth digit on the diagnosis code? to The diagnosis does not match the procedure, Cilento says. The questions go to the pediatrician for clarification before the claim is filed.

Code to the Highest Level of Specificity

Proper diagnosis coding is a persistent problem in pediatrics, Cilento says, and leaving out a fifth digit when one is required will result in a denial of the claim for truncated diagnosis. For example, pediatricians may indicate juvenile diabetes (250.0x) as a diagnosis. What they might not know unless they are told is that they need to use a fifth digit to indicate controlled (250.01) or not controlled (250.03).

Asthma is another common diagnosis for which the fifth-digit is crucial. Code 493.xx for asthma, with the fifth digit subclassification indicating no mention of status asthmaticus (493.x0), status asthmaticus (493.x1) or acute exacerbation (493.x2). The fifth digit is important for payment: Status asthmaticus would more readily justify a high-level office visit or a hospital admission than an asthma diagnosis without status asthmaticus.

Another typical problem is osteomyelitis (730.2x), Cilento says. You have to have the fifth digit for the site, she explains. When a pediatrician writes osteomyelitis, we always have to check the chart and discuss it with him.

There just isnt room on a superbill for all possible diagnoses, especially when additional digits are required, and therefore a back-and-forth between pediatrician and coder is necessary, at least until the pediatrician is familiar with the nuances of diagnosis coding.

In addition, the diagnosis must match the procedure. For example, lets say the diagnosis was gastroenteritis (008.8) and the pediatrician did a strep test (87880). Perhaps the child came in with a complaint of diarrhea, and the pediatrician, upon examination, discovered a very red throat and therefore decided to perform the test. The pediatrician did not realize that having one diagnosis code was not enough the diagnosis of acute pharyngitis (462) would have to be on the claim form as well, or the insurance company could deny the test.

Code Signs and Symptoms

Finally, pediatricians know but need to be reminded that there are no codes for rule-outs.

One solution to the rule-out problem is to remind physicians that they should use signs or symptoms until you have a firm diagnosis. For example, a child presenting with burning on urination should not have a diagnosis of urinary tract infection unless it is clear by urinalysis or culture that the child has a urinary tract infection. Do not instruct your biller to code rule-out urinary tract infection instead, use dysuria (788.1) if the complaint was pain upon urination.

I take these questions to the pediatrician, Cilento says. Even if I can fix the problem myself by looking at the chart, I show it to the pediatrician. This is partly because Cilento wants to make sure that the changes she has made fit the correct clinical scenario but also because she hopes to make the pediatrician aware of this for future reference. I talk directly to the doctors to try to educate them, she says.

The coding expert can keep the pediatricians informed of coding rules. This can be done in person, by memo, in meetings and on an ad-hoc basis as problems arise with claim forms.