On October 1, 2019, several changes came into effect in the ICD-10 codes for pediatrics. These ICD-10 code updates will impact family practice medical billing, and family practitioners need to ensure appropriate coding for appropriate reimbursement. There are changes to the tabular list as well as to ICD-10 pediatric code set. The American Academy of Pediatrics (AAP) recently published a report on these important updates, which are as follows:

Update to body mass index (Z68) introductory note: The new clarification regarding the Body Mass Index (BMI) guidelines is that the diagnosis associated with the BMI code (such as obesity) must meet the definition of a reportable diagnosis, not the BMI itself. The revisions to BMI ICD-10 code descriptions are as follows:

  • BMI adult codes are for use for persons 20 years of age or older
  • BMI pediatric codes are for use for persons 2‐19 years of age

These percentiles are based on the growth charts published by the Centers for Disease Control and Prevention (CDC).

In P22, respiratory distress of newborns, an “excludes 1” note was removed. The excludes notes within the P22 category are now as follows:

  • P22.0 Respiratory distress syndrome of newborn

Excludes2: respiratory arrest of newborn (P28.81)
: respiratory failure of newborn NOS (P28.5)

  • P22.8 Other respiratory distress of newborn

Excludes1: respiratory arrest of newborn (P28.81)
: respiratory failure of newborn NOS (P28.5)

  • P22.9 Respiratory distress of newborn, unspecified

Excludes1: respiratory arrest of newborn (P28.81)
: respiratory failure of newborn NOS (P28.5)

  • P22.1 (transient tachypnea of newborn) has no excludes notes

New 2020 ICD-10 Codes for Pediatric Conditions

In 2020, there are new codes for congenital deformities of the feet, Ehlers-Danlos syndrome, and Prader-Willi syndrome. The new ICD-10 codes for pediatric conditions in 2020 include the following:

Adenosine deaminase [ADA] deficiency

  • D81.30 – ADA deficiency, unspecified
  • D81.31 – Severe combined immunodeficiency due to ADA deficiency
  • D81.32 – ADA 2 deficiency
  • D81.39 – Other ADA deficiency

Congenital deformities of feet

  • Q66.9-* – Congenital deformity of feet, unspecified
  • Q66.7– – Congenital pes cavus
  • Q66.4– – Congenital talipes calcaneovalgus
  • Q66.1– – Congenital talipes calcaneovarus
  • Q66.0– – Congenital talipes equinovarus
  • Q66.3– – Other congenital varus deformities of feet

The appropriate 5th character to be added to these codes:
0 unspecified foot
1 right foot
2 left foot

  • Q66.21 – Congenital metatarsus primus varus
  • Q66.22 – Congenital metatarsus adductus

The appropriate 6th character to be added to these codes:

1 right foot
2 left foot
9 unspecified foot

Cyclical vomiting

  • R11.15 – Cyclical vomiting syndrome unrelated to migraine

Ehlers-Danlos

  • Q79.60 – Ehlers-Danlos syndrome, unspecified
  • Q79.61 – Classical Ehlers-Danlos syndrome
  • Q79.62 – Hypermobile Ehlers-Danlos syndrome
  • Q79.63 – Vascular Ehlers-Danlos syndrome
  • Q79.69 – Other Ehlers-Danlos syndromes

Eye and vision exam

  • Z01.020 – Encounter for examination of eyes and vision following failed vision screening without abnormal findings
  • Z01.021 – Encounter for examination of eyes and vision following failed vision screening with abnormal findings

Fracture of orbital wall

  • S02.12 – Fracture of orbital roof, closed fracture
  • S02.83 – Fracture of medial orbital wall, closed fracture
  • S02.84 – Fracture of lateral orbital wall, closed fracture

The appropriate 6th character to be added to these codes:

1 right side
2 left side
9 unspecified side

The appropriate 7th character to be added to these codes:

A initial encounter for closed fracture
B initial encounter for open fracture
D subsequent encounter for fracture with routine healing
G subsequent encounter for fracture with delayed healing
K subsequent encounter for fracture with nonunion
S sequel

Heatstroke

  • T67.01X – Heatstroke and sunstroke
  • T67.02X – Exertional heatstroke
  • T67.09X – Other heatstroke and sunstroke

The appropriate 7th character to be added to these codes:

A initial encounter
D subsequent encounter with routine healing
S sequela

G6PD

  • D75.A – Glucose-6-phosphate dehydrogenase (G6PD) deficiency without anemia

Latent tuberculosis

  • Z11.7 – Encounter for testing for latent tuberculosis infection
  • Z22.7 – Latent tuberculosis
  • Z86.15 – Personal history of latent tuberculosis infection

Poisonings

T50.911 – Poisoning by multiple unspecified drugs, medicaments and biological substances

The appropriate 6th character to be added:

accidental (unintentional)

2 intentional self-harm
3 assault
4 undetermined
5 adverse effect
6 underdosing

The appropriate 7th character to be added:

A initial encounter
D subsequent encounter
S sequela

Prader-Willi

  • Q87.11 – Prader-Willi syndrome
  • Q87.19 – Other congenital malformation syndromes predominantly associated with short stature

Pyuria

  • R82.81 – Pyuria
  • R82.89 – Other abnormal findings on cytological and histological examination of urine

Travel counseling

  • Z71.84 – Encounter for health counseling related to travel

*- Indicates that more characters need to be added to complete the code

Diagnostic Coding in Pediatrics – Points to Note

In a February 2019 article, the AAP provided key points to keep in mind to ensure appropriate ICD-10 code use in pediatrics, along with examples for each:

  • ICD-10 terminology – ‘other codes’, ‘unspecified codes’ and ‘and’
    • ‘Other’ codes or ‘other specified’ codes are used when the information in the medical record provides detail beyond the specificity of codes.
    • Codes titled ‘unspecified’ are used when a more specific code cannot be assigned due to insufficient information in the medical record. For categories that do not have an unspecified code, the ‘other specified’ code may represent both ‘other’ and ‘unspecified’.
    • When the word ‘and’ appears in a title, it should be interpreted as either ‘and’ or ‘or’
  • Etiology/manifestation convention ‘in diseases classified elsewhere’ note
    • The code title for manifestation codes will usually include ‘in diseases classified elsewhere. These ‘in diseases classified elsewhere’ codes cannot be used as first-listed or principal diagnosis codes. They must be used in conjunction with an underlying condition code, and must be listed following the underlying condition.
    • An ‘in diseases classified elsewhere’ code should not be reported when a code already combines the two.
    • An “in diseases classified elsewhere” code should never be reported alone.
  • Clinical terminology
    • Clinical documentation in the chart can impact code selection. Physicians need to ensure good clinical documentation that clearly conveys the intent of an encounter, confirm medical necessity, and provide detail to support ICD-10 code selection.

A reliable family practice physician billing company will have expert coders on board who are up-to-date with the latest changes and will use the right code for the situation, which is crucial for appropriate payment.