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Pediatric Coding Alert

Case Study:

Limit Lead Poisoning Diagnosis to Positive Test -- or Risk Fraud Charges

Better way: A high-risk V code can remedy payment woesYou're going to have to use an extra V code to separate routine lead screenings from exposure testings. See if you can navigate the nuances of ICD-9 coding for possible lead poisoning with this case study.The case: A hospital's adoption clinic routinely uses a lead poisoning diagnosis (984.9) on all patients to justify blood testing for lead. Is it appropriate for the clinic to use the poisoning code?No, says Jeffrey F. Linzer Sr., MD, MICP, FAAP, FACEP, associate medical director of compliance and business affairs for the division of pediatric emergency medicine Department of Pediatrics at Children's Healthcare of Atlanta at Egleston. "Billing for a condition that doesn't exist is fraud." Using the lead poisoning (984.9) diagnosis just to get paid for a test, especially if the patient is without symptoms and the screen is normal, is inappropriate. Linzer suggests that the clinic use this set of codes:• V70.3 -- Other medical examination for administrative purposes (adoption)• V15.86 -- Exposure to lead• V82.5 -- Special screening for chemical poisoning and other contamination.Reserve 984.9 for High LevelsYou should use the lead poisoning diagnosis only when a person has that condition. To enter 984.9, Linzer says, the physician must either:• "determine the patient has findings [or symptoms] consistent with the poisoning" or• interpret a lab test "as being consistent with poisoning or toxicity," meaning the test came back positive for high lead levels.Use Abnormal Code When Levels Are ElevatedThere's even a middle-of-the-road code you can use for elevated lead levels. When a child is asymptomatic for lead poisoning and the test results are positive for elevated levels of lead, you would report 790.6 (Other abnormal blood chemistry), Linzer says.Always Circle V82.5 as Your Screen DxFor the E/M encounter in which the pediatricians order the lead screening, you're going to use at least two V codes -- one for the service and one for the screening test.Easy: You'll always use the same diagnosis for the lead screening. Report V82.5 (Special screening for chemical poisoning and other contamination) when you test for lead contamination.Choose the service V code based on whether the pediatrician performed a preventive medicine service or an adoption exam. "At a well-child exam in which the pediatrician tests the 12-month-old for lead without a history of exposure, you would report V82.5 and V20.2 (Routine infant or child health check)," Linzer says. For an adoption exam (any age) that involves lead testing, use V70.3 and V82.5.Reality: Some plans will not pay for a routine lead screening's associated blood collection (36415 or 36416) or lab test (83655, Lead). One pediatric practice received lead screening test kits done by fingerstick that the manufacturer claimed insurers [...]