Being a parent of a new baby can be very challenging. The health and well-being of the baby is priority one. Many times parents want to bring in the child just to make sure everything is ok. The visit could be for a six-month-old child whose mother thinks they might be teething. Or maybe they have a cranky child who has had a previous ear infection that they simply want to have checked. This can also be related to older children that may have had a sprain or fracture. Once the visit is completed there is nothing wrong. The question remains, how do you code for this kind of visit?
Obviously you cannot bill for parental anxiety, but you can bill for the symptoms. Your answer can be the appropriate “Z” Code.
Z03.89 (Encounter for observation for other suspected disease and condition, ruled out), could be appropriate for these cases, particularly for those instances when a parent fears the patient has a problem but the visit results in no diagnosis.
How to apply it:
A mother brings her child who recently got over a cold to the pediatrician prior to a cross country trip to see family. “Just because I want to make sure everything is OK and the cold is gone,” the mom tells you. There are no signs, symptoms or problems other than the fact that the mom wanted to make sure that the cold is gone. This is a perfect place to use Z03.89 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 Z03.89 your best bet.
Where you don’t need it:
The mother brings in an infant saying that the baby has been pulling at his 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 an E/M code such as 99213 (Office or other outpatient visit for the evaluation and management of an established patient…). To support this E/M code, you should use otalgia (the affected ear was not specified, so the code would be H92.09) as the primary diagnosis. In this situation, you don’t need a Z code.
It is imperative to find out what the parents are worried about. Have the parent be as specific as possible about the illness they are afraid the child has so you can code the symptoms if necessary, as in the case of the otalgia case above.