Pediatric Coding Alert

Question: A 15-year-old female patient came to our office after rolling her right foot during dance class. A prior visit to the emergency department (ED) confirmed that she had a fracture of the fifth metatarsal, and when our pediatrician examined her for the first time, she was still experiencing difficulty walking - she was limping and experiencing significant foot pain with swelling and bruising. What ICD-10-CM codes do we use, and do we use initial or subsequent encounter seventh-character codes for this visit?

Connecticut Subscriber

Answer: You'll actually need to use a number of ICD-10-CM codes in this encounter, and not only will you need to be careful with seventh character use, you'll also need to make sure you get the codes in the correct order per the ICD-10-CM guidelines for sequencing.

Signs and symptoms first: Even though the ED visit provided a definitive diagnosis for your patient, you will still need to record the patient's signs and symptoms, as they are the reason for the encounter and the conditions that your provider will be treating. Or, as the ICD-10-CM guidelines put it, "while specific diagnosis codes should be reported when they are supported by the available medical record documentation ... there are instances when signs/symptoms or unspecified codes are the best choices for accurately reflecting the healthcare encounter."

So, in this scenario, you would report

• R26.2, - Difficulty in walking, not elsewhere classified
• M79.671 - Pain in right foot
• M25.474 - Effusion, right foot

Dx comes next: For a metatarsal fracture, you would look to S92.3 (Fracture of metatarsal bone(s)), and to S92.354 (Nondisplaced fracture of fifth metatarsal bone, right foot) specifically.

That's the easy part. The tricky part lies in not only remembering to add the seventh character to the code per ICD-10-CM guidelines for the S92 codes, but adding the correct one. As the patient has already been seen for the condition, it would be tempting to add character D ("Subsequent encounter for fracture with routine healing") or G ("Subsequent encounter for fracture with delayed healing") depending on your pediatrician's assessment of the patient.

However, the guidelines for Chapter 19 state that "while the patient may be seen by a new or different provider over the course of treatment for an injury, assignment of the 7th character is based on whether the patient is undergoing active treatment and not whether the provider is seeing the patient for the first time." In other words, determining the correct character has nothing to do with the provider at the initial encounter, but whether the encounter is for the purpose of diagnosing the patient or treating the patient's condition.

So, in this encounter, as your pediatrician's role is to treat the patient, you would add character "A" ("Initial encounter for closed fracture") as the seventh character to S92.354.

Code the external cause last: Well, technically speaking, "there is no national requirement for mandatory ICD-10-CM external cause code reporting," according to the guidelines, "unless a provider is subject to a state-based external cause code reporting mandate or these codes are required by a particular payer." But reporting the cause, intent, or location of aninjury yields useful data that, in the words of the ICD-10-CM guidelines, helps "to provide data for injury research and evaluation of injury prevention strategies."

From a strict coding standpoint, however, whether you are mandated, or if you choose, to report the external cause of injury (which, in this case, would be Y93.41 [Activity, dancing]), the code should appear at the end of the coding sequence. Again, ICD-10-CM guidelines come into play, as they specify that "the external causes of morbidity codes should never be sequenced as the first listed or principal diagnosis."

Putting it all together: With all this in mind, your final documentation should look like this:

• R26.2
• M79.671
• M25.474
• S92.354A
• Y93.41