Pediatric Coding Alert

Question: I have recently started working for a pediatric practice, and I’ve got a claim in front of me that gives me pause. Encounter notes indicate that the pediatrician performed a level-four evaluation and management (E/M) service for a new patient suffering from type 1 diabetes with moderate nonproliferative retinopathy and macular edema. That’s all the information I have to go on — can you help with ICD-10 coding?

South Carolina Subscriber

Answer: You probably have enough to file the claim — but in order to completely nail the ICD-10 coding, you’re going to need a slightly more detailed description of the encounter

Coding strictly from your description, you would report 99204 (Office or other outpatient visitfor the evaluation and management of a new patient, which requires these 3 key components:

a comprehensive history; a comprehensive examination; medical decision making of moderate complexity) with E10.3319 (Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, unspecified eye) appended to represent the patient’s diabetes.

If, however, you want to get the perfect diagnosis code, go back and check with the pediatrician. Ask her to be more specific about the location of the condition to, in the words of ICD-10, “designate laterality of the disease.” Then, choose from one of the following more specific ICD-10 codes:

• E10.3311, … right eye
• E10.3312, … left eye
• E10.3313, … bilateral

In the event that you cannot get a definitive location for the patient’s diabetes, however, you’re better off opting for E10.3319.