Pediatric Coding Alert

When a baby is (or might be) born affected by drugs or alcohol, the attending pediatrician can face difficulties coding the initial evaluation, and especially arriving at appropriate diagnoses. Sometimes symptoms are clear and can be easily listed, while at other times they are not readily apparent. Likewise, the pediatrician may not know if the mother has a history of alcohol or drug abuse. Older infants and children diagnosed for the first time with conditions caused by prenatal drug use can pose the same difficulties. To choose the most accurate diagnosis, pediatricians must consider the clinical information available and how that information fits existing ICD-9 codes.
 
Symptoms and Testing

According to Ira Chasnoff, MD, FAAP, president of Children's Research Triangle, a Chicago-based nonprofit organization that focuses on high-risk children, the best diagnosis code range for these cases is 760.7x (noxious influences affecting fetus via placenta or breast milk). The fifth digit of the ICD-9 code identifies the exact substance(s) the mother used, e.g., 760.72, ... narcotics.
 
Establishing a diagnosis is relatively simple when the symptoms are obvious, Chasnoff says, and is even simpler when the obstetric history shows maternal drug use. But do not code 760.7x based on maternal history alone. There must be documented symptomatology in the child as well.
 
Evidence of illegal substances in the mother's or newborn's urine is a clear although rare sign of drug exposure, Chasnoff says. You cannot, however, depend on drug tests to indicate prenatal drug exposure, which most likely occurred in the months before labor. Urine toxicology is usually negative because the metabolites are excreted within 48 hours of use. Furthermore, the presence of alcohol is not reflected in urine tests, only in blood tests (a moot point, as mothers don't drink in the hospital labor and delivery units).
 
Women often receive therapeutic medication during labor. Even though the effects of such medication notably, Demerol can confound simple urine toxicology results for narcotics, there are more specific tests to distinguish Demerol and other drugs, for instance, heroin. If the mother receives painkillers or other drugs during labor and/or delivery that harm the infant, report 763.5 (fetus or newborn affected by other complications of labor and delivery; maternal anesthesia and analgesia).

Maternal History

There is no code for a documented maternal history of drug or alcohol abuse, but because this clinical information affects the fetus, a 760.xx diagnosis is appropriate. You will need the maternal history to pinpoint the correct 760.xx code, however. There are no clear symptoms specific to each kind of drug" " Chasnoff says. Symptoms are general. Therefore you must rely on the maternal history to know if the drug used was cocaine heroin or something else.
 
For instance when Chasnoff's group evaluates a child who is in foster care for possible drug exposure (a full-day process) they always look in the state records to see if the mother abused any substances. If she did Chasnoff reports the appropriate code e.g. 760.75 ... cocaine. If the history indicates the mother used multiple drugs or drugs and alcohol the group claims all relevant diagnoses.

A newborn with a history of alcohol exposure should be coded 760.71 Chasnoff says. As the child ages the same code should be used for a diagnosis of fetal alcohol syndrome (FAS) or alcohol-related neurodevelopmental disabilities (ARND).
 
Most cases of alcohol exposure are not seen until the baby is older when certain characteristic signs emerge. For a diagnosis of FAS three criteria must be satisfied Chasnoff says: There must be the distinctive facial features there must be general growth impairment (below the 10th percentile) and there must be neurobehavioral problems. For a diagnosis of ARND two of the three criteria must be met. There are no specific diagnosis codes for these traits. Therefore a determination of ARND or FAS must clearly be linked to alcohol exposure in utero and not for example to growth impairment and/or neurobehavioral problems alone.
 
There are specific diagnosis codes for some of the traits that in turn are associated with neurobehavioral problems. A typical scenario involves a foster or adoptive mother who brings in a child with mild facial features (report the diagnosis code that describes the specific feature[s] noted) developmental delays (783.42) and hypotonicity (781.3) Chasnoff says. In this case the pediatrician doesn't know whether the birth mother had abused drugs or alcohol but is able to make a diagnosis of ARND.
 
Unlike alcohol exposure drug exposure in utero leads to no abnormal facial features Chasnoff says. Low birthweight or microcephaly may spur recognition of the problem.

Failure to thrive (FTT) (783.41) is commonly seen in older drug-exposed babies and may take a pediatrician by surprise if he or she didn't know that the baby had suffered drug exposure. In this case Chasnoff codes the drug exposure as the primary diagnosis and the FTT as the secondary diagnosis.
 
Richard H. Tuck MD FAAP founding chairman of the AAP coding and reimbursement committee suggests that pediatricians reverse the order of the diagnoses when FTT and drug exposure are evident. "Failure to thrive is a more complex diagnosis than drug exposure " he says. "Insurance companies may be more likely to pay for [FTT] at a higher level of E/M service."
 
Also the child might have been left with a mother who continued to use alcohol or drugs after birth. The pediatrician doesn't know if the FTT is due to the prenatal drug exposure or to neglect. Therefore many pediatricians choose FTT as the sole diagnosis.
 
"If we see a young infant with delayed motor development we code 315.4 (coordination disorder) " Chasnoff says. An older baby into the first year of life might exhibit hypertonicity (779.8) feeding problems (783.3) or delayed development (783.42). "For older children with delayed motor development code 783.4x (symptoms concerning nutrition metabolism and development; lack of expected normal physiological development in childhood) " Chasnoff continues. There's no age cutoff for determining fetal substance exposure Chasnoff notes. "For instance we just had a 17-year-old in for an evaluation who was diagnosed with fetal alcohol exposure."

One common problem which Chasnoff has written about in numerous studies is that many primary-care pediatricians tend to assume that their patient population has not been exposed to alcohol or drugs in utero. Often they believe this is a phenomenon that occurs only in inner cities with foster children or other situations that they view as outside their affluent patient population. This is a false assumption Chasnoff warns. "Watch out for social stereotypes. Do not allow them to influence your diagnosis " he says. "We have shown that abuse of illicit drugs and alcohol is just as high in upper classes as in lower."
 
Another problem is that pediatricians may mistake alcohol or drug exposure in utero to attention deficit hyperactivity disorder (ADHD) years later Chasnoff says. "The diagnostic criteria for ADHD may look a lot like what we see in substance-exposed children."

Some pediatricians worry that using an ICD-9 code that indicates fetal drug or alcohol exposure could require them to report the case to the authorities. Many pediatricians do report a baby born with fetal alcohol or drug exposure to the child-welfare authorities but it's not mandatory Chasnoff notes. The only reporting that's mandatory and only in a few states is when the baby has a positive urine or blood test for illegal drugs.