What diagnosis code can be used when a 14-month-old child is being followed because of preterm drug exposure? The insurance carrier will not accept the newborn code that indicates the child is a preemie.

Report International Classification of Diseases, Ninth Revision, Clinical Modification code V71.81 (observation and evaluation for other specified suspected conditions; abuse and neglect). The fact that the child was premature is now considered past history and noncontributory when it no longer affects the medical decision-making. If the encounter involved medical decision-making in which the prematurity history was a factor, it should be reported. Rarely will it be the sole diagnosis code as the problems that resulted in the encounter (eg, chronic lung disease, feeding problem) usually will be reported as primary with the prematurity codes reported as secondary.

Our physician sees a patient in her home when she is ill or to perform the preventive medicine visit...

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