Pediatric Coding Alert

Question: An insurance company has just denied us for an umbilical granuloma, telling us that P83.81 is the wrong ICD-10 code. Is this true? Should we appeal, or is there another code we can use?

AAPC Forum Participant

Answer: The correct code choice in this situation is based upon the age of the patient and payer preference. According to the ICD-10 guidelines accompanying the Chapter 16 (Certain Conditions Originating in the Perinatal Period [P00-P96]) codes, you would use P83.81 (Umbilical granuloma) if the patient is younger than 28 days, as “for coding and reporting purposes, the perinatal period is defined as before birth through the 28th day following birth.”

For patients 29 days or older you may have to use a less-specific code, most likely L92.9 (Granulomatous disorder of the skin and subcutaneous tissue, unspecified). And some payers may actually require two codes if the encounter begins as an office/outpatient evaluation and management (E/M) service and results in a cauterization for an umbilical granuloma that is not healing.

In an encounter like this, you would report P83.81 along with the appropriate E/M code from 99202-99215 (Office or other outpatient visit for the evaluation and management of a new/established patient …), then P02.60 (Newborn affected by unspecified conditions of umbilical cord) along with 17250 (Chemical cauterization of granulation tissue (ie, proud flesh)) for the cauterization. You would also attach modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the E/M.

In this particular scenario, it would be appropriate to use the Chapter 16 codes even if the patient is older than 28 days, as ICD-10 guideline I.C.16.4 tells you that “should a condition originate in the perinatal period, and continue through the life of the patient, the perinatal code should continue to be used regardless of the patient’s age.” As the granuloma had its origins in the perinatal period, this allows you to use P83.81 no matter how old the patient.