Pediatric Coding Alert

And make sure your practice is prepared for the worst.

Treating a child who has been physically or sexually abused has to be one of the most difficult tasks pediatricians face in their work.

Unfortunately, it is an all-too-common occurrence in contemporary pediatrics. That’s why we put together this guide to help you code the conditions accurately and help your entire practice work with victims if or when the situation arises.

Ask Suspected or Confirmed …

Before coding for any suspected or confirmed physical or sexual child abuse, you should become familiar with two different sets of ICD-10 guidelines, which are found in I.C.19.f. and I.C.20.g.

Guideline I.C.19.f. tells you to code confirmed cases of abuse or neglect with T74.- (Adult and child abuse, neglect and other maltreatment, confirmed), while suspected child abuse or neglect would be coded with a code from T76.- (Adult and child abuse, neglect and other maltreatment, suspected).

From a coding perspective, the distinction is significant as it affects subsequent code choices, as the guidelines go on to explain.

… Then Follow the Guidelines

For cases of confirmed abuse or neglect coded with T74.-, guidelines I.C.19.f. and I.C.20.g stipulate that an external cause code from the assault section (X92-Y09) should be added to identify the cause of any physical injuries. Additionally, a perpetrator code (Y07) should be added when the perpetrator’s identity is known.

And you will need to report the appropriate code from Z04.42 (Encounter for examination and observation following alleged child rape), Z04.72 (Encounter for examination and observation following alleged child physical abuse), or Z04.81 (Encounter for examination and observation of victim following forced sexual exploitation).

For suspected cases of abuse or neglect, the guidelines go on to instruct you not to report an external cause or perpetrator code. In addition, should your pediatrician eventually rule out the suspicion of neglect, abuse, mistreatment, rape, or exploitation, ICD-10 guidelines instruct you not to report a T76.- code at all. Additionally, you would not report one of the observation codes, as the first of the following case studies explains.

Remember to Code for Episode of Care: Because suspected or confirmed physical or sexual child abuse are reported with codes from the Injury, Poisoning, and Certain Other Consequences of External Causes (S00-T88) chapter of ICD-10, you will need to make sure that you add both a placeholder, X, and the appropriate character for the episode of care to make up the seven character code. This means adding either A (Initial encounter), D (Subsequent encounter), or S (Sequela) to the code to indicate the progress of the patient’s treatment.

Putting it All Together: Two Case Studies

Case Study 1: During an examination of a 10-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. However, further examination and questioning of the patient reveals that the boy had been involved in a particularly rough game of tackle football with his friends.

In this particular case, you would not report T76.12XA (Child physical abuse, suspected, initial encounter) as your pediatrician has ruled the physical abuse out after the examination. You would also not use Z04.72 “since the abuse was ruled out and there were symptoms of the injury present,” advises JoAnne M. Wolf, RHIT, CPC, CEMC, coding manager at Children’s Health Network in Minneapolis.

That’s because the observation Z codes “are only for use when a person is being observed for a suspected condition that is ruled out, not for an injury, illness, or signs or symptoms related to the suspected condition. 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 Y93.61 [Activity, american tackle football],” Wolf recommends.

Case Study 2: A 16-year-old female patient reports to your pediatrician and confides that she has been forcibly raped by her boyfriend and that this is the first time she has told anyone about the incident. Your pediatrician examines the patient and confirms the patient’s allegations.

In this case, Guideline 1.C.19.f comes into effect, and you would code T74.22XA (Child sexual abuse, confirmed, initial encounter). Also, “you would use Z04.42 as a secondary to the findings,” suggests Donelle Holle, RN, president of Peds Coding Inc., and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana.

Additionally, “I would code this with a code for any specific injury if documented in the chart and Y07.03 [Male partner, perpetrator of maltreatment and neglect] per ICD-10 guidelines to indicate it was the female patient’s boyfriend who was the perpetrator,” Wolf adds.

Pro Coding Tip: “Typically, the evaluation and management (E/M) code for these types of visits will be billed based on time due to the extensive counseling that will have to take place, along with referrals and police reports that will have to be filed,” Holle recommends.

Go Beyond the Codes

Of course, the issue of child abuse goes beyond simply coding for the patient’s situation. Before you or anyone in your practice encounters a case of suspected or confirmed child physical or sexual abuse, the American Academy of Pediatrics (AAP) recommends that your practice “has a protocol in place to respond that is consistent with legal reporting requirements, state-based statutes, and utilizes appropriate community resources.” That includes knowing which authorities to contact and deciding on a safe place for the child when such an event occurs (Source:  www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/resilience/Pages/Child-Abuse-and-Neglect.aspx).