Pediatric Coding Alert

Stay on top of opportunities to report SDoH.

As a peds coder, you’re used to coding new patient encounters. After all, babies are born all the time. But sometimes the new patients aren’t newborns, and the information can get confusing, especially if the patient has an existing condition such as type 1 diabetes. The potential for miscoding is always lurking.

With the following case study, we’ll walk you through coding such a new patient encounter, starting with whether to use time or medical decision making (MDM) to level the evaluation and management (E/M) service, moving on to applicable ICD-10 codes, then finishing with insight into social determinants of health (SDoH).

Review This Scenario

A new patient comes in complaining of blurry vision. The pediatrician spent 10 minutes right before the appointment reviewing the patient’s existing records, which includes a diagnosis of type 1 diabetes with insulin compliance and no previous complications. The current pediatrician suspects the vision problems might be nonproliferative retinopathy and macular edema and refers the patient to an ophthalmologist. The E/M portion takes 43 minutes and includes a look into the patient’s eyes as well as patient and parent counseling about diabetes maintenance. A portion of the exam includes discussion of financial hardship and its negative effect on adequate nutrition.

Decide Whether to Use Time or MDM

MDM: It’s important the physician gets reimbursed in a way that most accurately accounts for their work and expertise. Let’s figure out how this encounter might level if you were to use MDM.

The encounter must meet two of the three elements of MDM: number and complexity of problems, data to be reviewed and analyzed, and risk.

Number and complexity of problems: The patient presented with blurry vision, which by itself is a minor problem; but the diabetes is potentially a more serious situation. Since the physician suspects the diabetes is not stable or has created the eye problem, that alone suggests this might fit better at a 99204 (Office or other outpatient visit for the evaluation and management of a new patient… moderate level…) rather than a 99203 (… low level…). When you look at the criteria for reporting 99204, the suspicion of exacerbation of the diabetes might be enough to satisfy this element. However, it’s not a sure fit either way.

Data to be reviewed and analyzed: The physician reviewed prior records, but there were no other documents to assess or analyze, so that takes the data element out of consideration for 99203 as well as 99204.

Risk: Additional testing would likely be considered low risk, which could help fulfill the criteria for a 99203 for the encounter. But again, this is not taking the comorbid condition, the diabetes, into consideration. There may be appropriate risk involved to justify 99204 when you factor in the SDoH potentially interfering with treatment, but like the other elements, it’s not clear.

Using MDM raises more questions than answers, and makes it difficult to pinpoint the exact level of the E/M, so let’s see what happens when we consider time instead.

Time: The pediatrician made sure to include the exact number of minutes spent during the encounter, including justification for that time. You might know right off the bat that 43 minutes on a new patient translates to 99203 (… 30-44 minutes of total time...). However, that is right on the cusp of being a level four, so since the physician spent an additional 10 minutes before the appointment on the day of the actual encounter, this easily levels up to 99204 (… 45-59 minutes...). Remember, the time spent preparing to see the patient, reviewing the medical record from the patient’s previous physician, and even documenting the clinical information obtained are all valid billable minutes.

Now that we’ve got the E/M level settled, let’s walk through the appropriate ICD-10 codes.

Code the Symptoms and Comorbid Condition

While you may be tempted to turn to the E10.3- (Type 1 diabetes mellitus with ophthalmic complications) codes, remember that there wasn’t a formal diagnosis. The pediatrician suspects this patient might be suffering nonproliferative retinopathy and macular edema due to the diabetes, but the patient has yet to see the specialist. This means the blurry vision is all you have to go on, which you’ll address using the H53-H54 code set for visual disturbances and blindness.

Symptom: As you navigate this code set, however, you’ll notice that there isn’t a code specific to blurry vision. However, the Alphabetic Index associates “blurred, blurring” with H53.8 (Other visual disturbances). Therefore, since that is the symptom for which the patient sought treatment, and no other symptoms were recorded, H53.8 is the only appropriate symptom code to report. This should be coded first, as instructed in section I.C.4.a of the ICD-10 guidelines: “As many codes within a particular category as are necessary to describe all of the complications of the disease [diabetes mellitus type 1] may be used. They should be sequenced based on the reason for a particular encounter.”

Diabetes: Type 1 diabetes is clearly documented by the previous physician and should be included as a comorbid condition. Therefore, you’ll select the most appropriate code from E10.- (Type 1 diabetes mellitus), which in this case looks to be E10.9 (Type 1 diabetes mellitus without complications). Be aware that electronic medical records (EMRs) often default to E11.- (Type 2 diabetes mellitus), which is always something to watch out for.

Coding alert: Remember that reporting comorbid conditions such as type 1 diabetes is a type of validation of time spent. “Complete and specific diagnosis coding can help support a higher level of time when appropriate. For example, just listing conditions in the assessment shows that you are aware of them,” says Kate Tierney, CPC-I, CPMA, CPC, CPC-P, CRC, COGC, CGSC, CEMC, CEDC, CBCS, CMAA, CICS, CHI, CEHRS, CPhT, national coding trainer for Optum RQNS in Highlands Ranch, Colorado.

Coding alert: Type 1 diabetics are insulin-dependent, whereas some type 2 diabetics can control their condition with diet. It’s because of this difference that there’s a note accompanying E11.- codes that instructs you to use an additional code to identify control with the correct Z79.- (Long term (current) drug therapy) code. So even though you may be tempted to report Z79.4 (Long term (current) use of insulin), ICD-10 assumes all type 1 patients will be long-term users, and therefore it’s not necessary to report the code.

Remember Social Determinants of Health

Focusing on the management of a patient’s diabetes is important as a coder but painting a complete picture by reporting noted SDoH is an effective way to help current and future healthcare providers come up with complete treatment solutions. In a 2015 study published in Health Expect centered around how SDoH can impact young peoples’ capacity to manage their type 1 diabetes, the authors conclude that full and comprehensive care relies on recording a detailed social history (https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC5810664/).

In fact, ICD-10 2023 updates included similar instruction regarding SDoH codes. Section I.C.21.c.17 of the guidelines reads, “Assign as many SDOH codes as are necessary to describe all of the problems or risk factors.” It goes on to explain that you should assign codes based on documentation that specifies the patient has an associated problem or risk factor.

The pediatrician in the case study scenario took such care, and based on that evaluation, the following SDoH codes apply:

• Z59.86 (Financial insecurity)
• Z59.48 (Other specified lack of adequate food)

Wrap it up

First, code the E/M service: This encounter levels to 99204; include all the documentation to justify the time spent.

Second: List the reason for the encounter, which is the blurry vision, with H53.8.

Third: List the comorbid condition, previously classified as having no complications, with E10.9.

Last: Code for the SDoH with Z59.86 and Z59.48.