Pediatric Coding Alert

Here’s what to do when ICD-10 guidelines seem to contradict.

Since the beginning of your coding career, you have known to apply ICD-10 Guideline IV.H to your pediatrician’s notes when they indicate they have not confirmed a diagnosis, and not to record that diagnosis in the patient’s medical record.

As a reminder, that’s the guideline that tells you not to “code diagnoses documented as ‘probable,’ ‘suspected,’ ‘questionable,’ ‘rule out,’ ‘compatible with,’ ‘consistent with,’ or ‘working diagnosis’ or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit.”

But does that rule apply in cases of child neglect, maltreatment, or other forms of abuse when they are suspected and eventually ruled out? Here’s what you need to know when confronted with this thorny issue.

First, let’s look at a typical scenario that could come into play during your time as a pediatric coder.

Is This Suspected Abuse?

During an examination of a 13-year-old male patient, your pediatrician discovers extensive bruising around the child’s buttocks and left thigh. Your pediatrician initially suspects that the child’s father has physically abused him, based on the fact child refused to talk about the incident that caused the injuries and the fact that the child’s father had a reputation for violence. The pediatrician documents that the child may have been physically abused.

However, subsequently the child explains that he had received the injuries following a fall from his bicycle, and that he didn’t want to talk about them initially as he had been with friends his parents had told him not to be with, and in a part of town he was not supposed to go.

How to Code This Scenario

Clearly, the first codes that come to mind for this encounter are injury and external cause codes. “In this case, I would code S30.0XXA [Contusion of lower back and pelvis, initial encounter] and S70.12XA [Contusion of left thigh, initial encounter] and add a corresponding external cause code,” such as V18.2XXA (Unspecified pedal cyclist injured in noncollision transport accident in nontraffic accident, initial encounter) says JoAnne M. Wolf, RHIT, CPC, CEMC, coding manager at Children’s Health Network in Minneapolis.

The issue then becomes what, from a coding perspective, should you do about the physical abuse that your provider suspects?

Does Guideline I.C.19.f. Take Precedence Over IV.H?

The short answer is, yes. Simply put, there are a number of ICD-10 codes that will override guideline IV.H based on the fact that they include the words “suspected” or “ruled out.”

In this particular case, though, that will not lead you to code the scenario correctly. Per I.C.19.f. you are told that if the documentation in the medical record states the abuse or neglect is suspected “it is coded as suspected and documented as suspected (T76.-).” The guideline also tells you to “sequence first the appropriate code from categories T74 … or T76 … followed by any accompanying mental health or injury code(s).”

But before you reach for T76.12XA (Child physical abuse, suspected, initial encounter) and sequence it as the first-listed code before the three other codes already selected to document the encounter, you need to read further into the guideline. There, you are told that “if a suspected case of abuse, neglect or mistreatment is ruled out during an encounter,” you should code Z04.72 (Encounter for examination and observation following alleged child physical abuse, ruled out) “not a code from T76.”

Yet even using that code would be incorrect “since the abuse was ruled out and there were only symptoms of the injury present,” says Wolf. So, you are left simply using the two injury codes and the external cause code to document the scenario.

So, When Do You Use a Suspected or Rule Out Code?

Ultimately, this has to be a judgement call on the provider’s part. Factors such as family or personal history of abuse, an examination inconsistent with the patient’s chief complaint, or even legal considerations, such as mandatory state abuse reporting requirements, could possibly come into play. In other words, even though you can use guideline I.C.19.f. to override IV.H doesn’t mean you need, or even should, use it in all cases of suspected abuse when your pediatrician rules it out.