Otolaryngology Coding Alert

Review all the most important ICD-10-CM guidelines on P codes here.

Pediatric coding is often viewed under its own, individual diagnostic lens as compared to the rest of the ICD-10-CM manual. That’s in part because P codes make up a single chapter in the ICD-10-CM, yet are responsible for covering conditions affecting numerous different body structures and organ systems.

For this reason, it’s important that coders do their due diligence when it comes to grasping each of the important guidelines listed in Chapter 16: Certain Conditions Originating in the Perinatal Period (P00-P96).

Rely on these ICD-10-CM instructions, and subsequent examples, to make sure you are reporting your P code claims with accuracy and efficiency.

Use Perinatal Period Timeframe as a Start, End Point

Before beginning in any other facet of pediatric coding, you must know what criteria need to be met in order to report P codes. ICD-10-CM states that, “For coding and reporting purposes the perinatal period is defined as before birth through the 28th day following birth.” This means that you should only consider P codes for pediatric conditions that affect the patient on or up to the 28th day following birth.

Caveat: There’s one important caveat here that coders must consider. Also, within Chapter 16 of the ICD-10-CM guidelines, ICD-10-CM states the following:

• “Should a condition originate in the perinatal period, and continue throughout the life of the patient, the perinatal code should continue to be used regardless of the patient’s age.”

This particular guideline, understandably, can be a source of confusion for even the most experienced coders. Unfortunately, you won’t find any additional elaboration within the ICD-10-CM or any other authoritative manual — so it’s up to the coder to make a final judgement as to what exactly this guideline means.

Typically, coders might assume that if the patient experiences a condition that extends outside of the perinatal age range, you should graduate to diagnosis codes outside of Chapter 16. However, it’s not always that simple. The answer comes down to how you interpret the guidelines. You might work under the assumption that if the patient experiences an acute condition that extends beyond the perinatal period, you should continue to use a P code until the condition is resolved. Other coders, however, believe that these guidelines are more applicable to lifelong, congenital conditions.

“I’ve always interpreted this particular guideline as specific to congenital diseases,” says Lindsay Della Vella,  COC, medical coding auditor at Precision Healthcare Management in Media, Pennsylvania. “A condition originating in the perinatal period and ‘continuing through the life of the patient’ is highly unlike to be acquired following birth. Additionally, any acquired condition in the perinatal period is likely to be treated,” Della Vella explains.

While no authoritative source exists to confirm one way or the other, the wording behind the guidelines seem to suggest the latter as the correct option. Take a look at the following two examples to gain a clearer picture.

Rely on Documentation, Etiology for Conditions Outside Perinatal Period

Discerning between a congenital versus chronic condition can be difficult at times. The degree of difficulty is compounded when the condition arises in the first few weeks following birth. Consider these two examples to help paint a clearer picture.

Example: 1-year old presenting with chronic bronchopulmonary dysplasia since birth.

Keep in mind that, for most congenital conditions, you will opt for a code within Chapter 17: Congenital malformations, deformations, and chromosomal abnormalities (Q00-Q99). However, in the example above, you will report code P27.1 (Bronchopulmonary dysplasia originating in the perinatal period). Ideally, the documentation should support your use of a P code outside of the perinatal period by identifying that the condition arose in the perinatal period. If the payer denies this code due to use outside of the perinatal period, you should submit an appeal citing the guidelines above.

Example: Newborn presents with a right middle ear infection at 5 days old. The patient is treated and returns with the ear infection persisting at 30 days old.

Coding the initial ear infection is as simple as reporting code P39.8 (Other specified infections specific to the perinatal period). However, when considering the guidelines, the follow up diagnosis code becomes less clear. Your options are either to report P39.8 again during the follow up visit or report code H66.91 (Otitis media, unspecified, right ear). Following verbatim by the ICD-10-CM guidelines, you might imagine that you should report a P code for this clinical encounter. However, the insurance company will likely flag the patient’s age as incompatible with the code assigned.

For a treatable condition such as an ear infection, you should typically not resort to using a P code following the perinatal period. P codes outside of the perinatal period should be designated for conditions that are chronic, potentially lifelong afflictions.

Only Code Community Involvement With Appropriate Documentation

Here’s another set of crucial guidelines on how to address a patient’s condition when the etiology is not entirely clear:

• “If a newborn has a condition that may be either due to the birth process or community-acquired and the documentation does not indicate which it is, the default is due to the birth process and the code from Chapter 16 should be used. If the condition is community-acquired, a code from Chapter 16 should not be assigned.”

“‘Community-acquired’ describes a condition contracted outside the healthcare setting, in this case, after a newborn has gone home,” says Sheri Poe Bernard, CPC, of Poe Bernard Consulting in Salt Lake City, Utah. “Querying the provider is another alternative before coding the source of infection in a newborn. If a query is not practical or possible, the guideline tells us to assume the infection was relayed to the newborn from the mother, rather than from the newborn’s surroundings,” Bernard explains.

These guidelines can certainly prove tricky depending on the clinical encounter you are coding. For instance, if a newborn patient presents with a chronic cough, you shouldn’t automatically opt for a P code. First, check the documentation. If there is some indication that the cough is a result of exposure to another individual within the community, for instance, then you should opt for R05 (Cough), not P28.89 (Other specified respiratory conditions of newborn). However, the documentation surrounding the encounter typically will not make inferences about community involvement. If there is no reference to community involvement, you report the cough using code P28.89.

Use Supplementary Diagnosis Codes, When Appropriate

Finally, have a look at this policy on reporting codes from outside chapters as supplementary codes to P codes:

• “Codes from other chapters may be used with codes from chapter 16 if the codes from the other chapters provide more specific detail. Codes for signs and symptoms may be assigned when a definitive diagnosis has not been established. If the reason for the encounter is a perinatal condition, the code from chapter 16 should be sequenced first.”

One myth that many within the coding community subscribe to is that, when reporting a P code to address a patient’s condition, diagnosis codes from other chapters are not to be included. On the contrary, ICD-10-CM advises coders to include diagnosis codes from outside chapters when the code may provide additional detail to the patient’s condition. Use the example above in which the physician treats a newborn with for a chronic cough. In this example, assuming no community involvement, you may report P28.89 as the primary diagnosis code and R05 as a secondary diagnosis code.