Pediatric Coding Alert

ICD-9 2010 threw you a curve ball: You have more specific pediatric codes, but you have to know cut-offs for newborn, infant, adolescent, and adult. That's not an easy task.

Reference sources have different definitions for the same word, reports Jamie Kurrasch, CPC, at Primary Care Partners PC in Grand Junction, Colo. "This makes applying the correct ICD-9 code difficult."

Check out how different cut-off ages affect selecting the ICD-9 code for this case.

"The ICD-9 code for fussy infant is 780.91 (Fussy infant [baby])," Kurrasch points out.

Problem: One source states an infant is a child below the age of two, and another source states an infant is a child below the age of 12 months, Kurrasch reports. "So if I have a patient that is 16 months old, by one source's definition of 'infant' 780.91 is appropriate, but not by the other source's definition."

Both CPT and ICD-9 are consistent in defining a newborn's age, says Richard Tuck, MD, FAAP, pediatrician at PrimeCare of Southeastern Ohio in Zanesville. The newborn is birth through 28  days.

"CPT defines the language in Newborn Care Services preceding the 99460-99465 series," Tuck points out. "The following codes are used to report the services provided to newborns (birth through the first 28 days)," according to CPT 2009 Professional Edition, page 32.

The newborn health supervision codes are then further broken down in ICD-9. Code V20.31 (Health supervision for newborn under 8 days old) is for a newborn health check when the patient is less than eight days of age. Code V20.32 (Health supervision for newborn 8 to 28 days old) applies for a health check of a patient who is eight through 28 days of age.

Catch: Newborn is about the only age that CPT and ICD-9 clearly define, says Jeffrey F. Linzer Sr., MD, MICP, FAAP, FACEP, associate medical director of compliance and business affairs for the Emergency Pediatric Group at Children's Healthcare of Atlanta at Egleston. "Otherwise, ICD does not define age except one other circumstance." For the pediatric body mass index (BMI) codes (V85.5x), ICD uses the Centers for Disease Control and Prevention definition, age up to (and including) 20 years.

Be sure to check your major payers' policies as insurers can vary. For instance, CMS uses less than 18 for its pediatric diagnosis-related groups (DRGs).

"ICD language considers the infant or child to be more than 28 days of age," Tuck says. There's no clear delineation of infant to child in ICD.

Tip: You can use CPT's preventive medicine service age groupings as a guide. The language for 99381 (Initial comprehensive preventive medicine evaluation and management of an individual ...) and 99391 (Periodic comprehensive preventive medicine reevaluation and management of an individual ...) is for "infant (age younger than 1 year," which then progresses to 99382 and 99383 for "early childhood (age 1 through 4 years)", Tuck points out.

Generally, infancy is considered the first year of life and early childhood starts in the second 12 months, agrees Linzer. "But this cut-off isn't hard and fast." ICD-9 gives you some latitude in applying 780.91 "I wouldn't get tied up about using the fussy-infant (baby)  code for an 18-month-old child," Linzer says. Since the age is not well defined, physician discretion is appropriate.

Action: Check to see if your major payers give you as much leeway. Private payers may have software edits based on Medicare's Code Editor (MCE) that restrict 780.91 to newborns and neonates (indicated with an "N" in the ICD-9 2010 manual).

The MCE detects inconsistencies between a patient's age and diagnosis. If you submit a newborn code for a patient older than zero years of age, the system will deny the claim presuming either the diagnosis or the age is incorrect.

The next break you have is from childhood to adolescence. CPT defines these groups in the preventive medicine codes using 99383 and 99393 for late childhood (age 5-11) and 99384 and 99394 for an adolescent (age 12 to 17 years). "Adolescence is easy: When they whine about the computer, going out with their friends or wanting the car, they're an adolescent (meaning teens)!" Linzer quips.

Applying CPT's groupings to preventive medicine services diagnoses, you would use V20.2 (Routine infant or child health check) though 17 years of age and then switch to V70.0. Check with insurers, however, as their guidelines may vary. The MCE designates V20.2 as a pediatric code: age 0-17, but assigns no age symbol to V70.0 (Routine general medical examination at a health care facility).