Revenue Cycle Insider

Question: I work at a pediatrician’s office that sees some older children whose encounters may involve conversations more in the sphere of young adulthood rather than childhood. I know there are ICD-10-CM guidelines for codes specific to newborns, which it defines as a child younger than 28 days. Are there any similar guidelines for teenagers versus adults?

Arkansas Subscriber

Answer: According to AHA ICD-10-CM Coding Clinic, “there are no official guidelines or coding instructions (except in a few specific codes like the pediatric body mass index codes) that distinguish pediatric from adult diagnoses. This is a payer edit issue; therefore, contact the specific payer to determine what, if any, age edit applies” (2017 Volume 4, Number 4).

In your situation, you should check with the respective payer to see how they decide when, say, an annual visit is considered a routine child well check versus a preventive medicine encounter for an adult. For example, well-check codes are subject to age-specific Medicare code edits (MCEs), which instruct you that Medicare will reimburse for a Z00.12- (Encounter for routine child health examination) code only for patients from the age of 0 through 17 years old and a Z00.0- (Encounter for general adult medical examination) code for patients older than 18 years of age.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Development Editor, AAPC