Pediatric Coding Alert

Look to guidelines and infant age for specificity in this scenario.

The scenario may be familiar, and if it isn’t, it may seem straightforward enough. Yet this encounter with a neonate struggling to breastfeed will test your ICD-10-CM coding knowledge as you rule numerous codes in or out of your reporting.

Carefully read through the following scenario, then open up your ICD-10-CM manual to the index. But keep those guidelines bookmarked, too, as they will help you with your choices should the condition extend beyond the neonatal period.

The Scenario

A 10-day-old male presents with problems breastfeeding. The child’s mother tells your pediatrician that the child is eating slowly and briefly; the child is swallowing but vomits a small amount of whitish-colored fluid shortly after being burped. The baby is having frequent, normal bowel movements, and your pediatrician’s examination of the baby’s gastrointestinal system reveals no problems. However, the pediatrician notes that the baby has lost about five percent of his birth weight, though the child is currently at 6 lb. 11 oz., which puts him in the tenth percentile for his age and weight.

What ICD-10-CM Codes Come into Play?

As a peds coder, you know that the child’s age will be a significant factor in the code choice for this encounter. It will preclude use of R63.3 (Feeding difficulties) and codes from F50.- (Eating disorders), which you would use for patients over 28 days old.

Instead, as the child is still a neonate, the codes you will need will be in the P92 (Feeding problems of newborn) block, as Donelle Holle, RN, President of Peds Coding Inc., and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana, points out. Specifically, Holle argues, as the chief complaint is the child’s problem with feeding, P92.5 (Neonatal difficulty in feeding at breast) would probably be the best code choice, depending on your pediatrician’s assessment and documentation.

Chelle Johnson, CPMA, CPC, CPCO, CPPM, CEMC, AAPC Fellow, billing/credentialing/auditing/coding coordinator at County of Stanislaus Health Services Agency in Modesto, California, agrees with the choice of P92.5 as the primary diagnosis for the visit. Then, Johnson would add P92.1 (Regurgitation and rumination of newborn) for “the regurgitation of the milk with a short period of time after eating.” That would be preferred to P92.01 (Bilious vomiting of newborn), as this kind of vomit would be yellowish or greenish, or P92.09 (Other vomiting of newborn), which lacks the specificity of P92.1.

Additionally, both Holle and Johnson would use P92.6 (Failure to thrive in newborn) due to the baby’s weight loss.

How Would You Code the Encounter?

Importantly, in this encounter, you would not document the child’s body mass index, or BMI. Johnson reminds coders that “you would not note the patient BMI, as BMI is only related to patients 2 years and older,” reinforcing the ICD-10-CM guidelines prior to the Z68.- (Body mass index) code group.

However, you will be able to apply Z05.5 (Observation and evaluation of newborn for suspected gastrointestinal condition ruled out) to this scenario to reflect the results of your pediatrician’s examination of the child’s gastrointestinal system and the fact that it revealed no problems. As Holle points out, this also has the advantage of boosting you claim for reimbursement, as “the more diagnosis codes applied to a CPT^® code, the more likely the reimbursement will be appropriate.”

E/M Coding Presents an Additional Challenge

Holle suggests that the level of evaluation and management (E/M) service bedetermined by time as “typically, with this type of weight loss, there will be an extensive amount of counseling on the weight loss, the breastfeeding and the plan.

“With two of three key factors, the expanded problem-focused exam briefly looking at two to seven systems but a low-level illness with low-level MDM determined by the acute risk and worsening patient problem, this would be a 99213 [Office or other outpatient visit for the evaluation and management of an established patient …] visit,” Holle reasons. “But when using time,” Holle adds, “the visit could well rise to a 99214 and if, in fact, they had 33 minutes of total time, with greater than 50 percent in counseling concerning all of the issues that were presented, it could even rise to 99215.”  

One Final Note of Coding Caution

The code choices for this encounter are all based on the patient’s age at the time of the encounter. But what happens if the condition continues beyond 28 days, which marks the end of the perinatal period per ICD-10-CM guidelines? Guideline 16.a.4 notes that “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.”

So, if the condition is newly diagnosed after that 29 days, you would use the F50.- codes. But should the patient report back 29 days after birth when he is no longer classified as a newborn, and the condition has not changed, you would still go ahead and code P92.2 with P92.8 and not change the diagnosis to a code from F50.-. However, in this case, as Holle notes, “the insurance carrier may not recognize that the code can be used past 28 days of age, so they may deny it, saying that the age and ICD-10-CM code do not match. If that occurs,” Holle suggests, coders should “appeal the denial using the actual verbiage from the ICD-10-CM guidelines.”

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