Question: A mother brought in an infant saying that the baby had been pulling at his ears. On exam, the child had no fever and the ears looked fine. The child was well, but our pediatrician had to spend a considerable amount of time making this determination, warranting a 99213 (Office or other outpatient visit for the evaluation and management of an established patient). Which diagnosis codes should we report? Sick or well? Our office manager suggested V71.9 but it doesn’t seem right.
Answer: To support the E/M code, you should use V71.89 (Observation of a specified condition ) since no more specific diagnosis was found during the visit.
It is very important to push to find out what the parents are worried about in situations like this one. Get them to be as specific as possible about the illness they are afraid the child has—if so, you can code that suspected diagnosis first and V65.5 (Person with feared complaint in whom no diagnosis was made). 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.