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Thread: Fussy Infant

  1. #1

    Default Fussy Infant

    AAPC: Back to School
    A mother brought her 2 year old child into the office with a complaint of being fussy. Upon exam, the provider found nothing wrong and administered a flu vaccine per the mother's request. The provider used code 780.91 (fussy infant/newborn) as the primary dx (along with V04.81 for the vaccine), but our billing edits rejected this code because of the patient's age.

    Per ICD-9 guidelines, if you have no definitive diagnosis, you code signs and symptoms, which the provider did here, but code 780.91 is for an infant/newborn and a 2 year old child is not an infant or newborn (per our billing edits).

    So how do we code this? Is code 780.91 correct, or should we go with V65.5 for feared complaint but no diagnosis made?

    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P
    Compliance Auditor

  2. #2


    Since the patient is 2, use 780.95 instead of 780.91

  3. #3


    I considered 780.95, but that code is for excessive crying of a child, adolescent, or adult. There is no documentation that the child has excessive crying. In fact, they weren't crying at all during the exam (not that is documented anyway). The provider says the patient was happy in the clinic. The CC just says fussy and nothing was found. The HPI says the patient has a mild runny nose, but that is not why the patient was seen. The mother brought the child in because he was fussy,but nothing was found to be wrong.

    Any thoughts?
    Last edited by dballard2004; 01-19-2011 at 10:54 AM.
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P
    Compliance Auditor

  4. #4
    Join Date
    Apr 2007
    Columbia, MO


    I would go with the V71.xx for the primary for observation for a suspected condition but not found, and then why not the 780.91, or nothing secondary.

    Debra A. Mitchell, MSPH, CPC-H

  5. #5


    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P
    Compliance Auditor

  6. #6


    Definitely would use the V65.5 dx since there was no problem found. We use this dx in our office when no problem is found by the provider.
    Jutta Whipkey, CPC

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