Pediatric Practices Could Take Financial Hit if ICD-10 Documentation Isn't Specific

By Lisa Eramo  |  November 6, 2014

ICD-10 Resource CenterAttention pediatricians: The transition to ICD-10 could have a particularly significant impact on your practice’s bottom line, according to new research conducted by the University of Illinois at Chicago. Tweet this Kareo story

Using a web-based tool developed at the university, researchers analyzed 2010 Illinois Medicaid data to discover that 26% percent of pediatric ICD-9-CM codes have convoluted mapping to ICD-10-CM.  This means that converting these codes to the new coding system is either complex or difficult, oftentimes demanding documentation specificity.

In a specialty that already has a low financial margin, ensuring thorough documentation practices will be critical, says Jackie Stack, CPC, CPB, CPC-I, CEMC, CFPC, CIMC, CPEDC, director of ICD-10 training and education at the American Academy of Professional Coders. Many of the diagnoses that pediatricians report frequently are now much more specific. If pediatricians continue to document as they do today, these diagnoses will map to unspecified codes in ICD-10 that payers may not reimburse.

Stack says pediatricians should focus on these diagnoses that will require additional documentation in ICD-10-CM:

Asthma (J45.-)
In ICD-10-CM, documentation of ‘asthma’ is not sufficient. Instead, pediatricians must specify the type of asthma (i.e., mild intermittent, mild persistent, moderate persistent, severe persistent, or other) as well as whether the asthma is uncomplicated, with exacerbation, or with status asthmaticus. An additional code is necessary to denote the cause of the asthma (e.g., exposure to environmental tobacco smoke, history of tobacco use, or occupational exposure to environmental tobacco smoke).

The National Heart Lung and Blood Institute publishes guidelines regarding the classification of asthma and clinical criteria. See p. 5 of the Asthma Care Quick Reference Guide, and be sure to stick to these definitions.

Otitis media (H65.- to H67.-)
In ICD-10-CM, documentation of ‘otitis media’ is not sufficient. Instead, pediatricians must specify the type of otitis media (e.g., serous, sanguinous, suppurative, allergic, mucoid), the severity (i.e., acute, chronic, subacute, or recurrent), and laterality (i.e., left, right, or bilateral). Additional codes must be assigned to denote the presence of any associated perforated tympanic membrane as well as any environmental factors (e.g., tobacco use, tobacco dependence, or history of tobacco use).

Well-child exam (Z00.11- and Z00.12-)
ICD-9-CM includes one code for a well-child exam (V20.2 or V20.3x, depending on the child’s age). ICD-10-CM provides more options because it also distinguishes between ‘with abnormal findings’ and ‘without abnormal findings.’ Be sure to document the specific abnormal finding, when present.

The distinction between ‘with’ and ‘without’ abnormal findings could benefit pediatric practices because it may bolster support for providers to be able to separately bill for an evaluation and management service. For example, if during a well-child exam, a provider uncovers, evaluates, and treats an ear infection, he or she may be able to bill for the well-child check with abnormal findings as well an office visit with a modifier -25. Physicians should clearly document the treatment and evaluation of any abnormal findings that they discover. Stack also cautions providers to check with their insurance carriers before implementing this process.

Encounter for immunization (Z23). In ICD-9-CM, each immunization procedure code required a corresponding diagnosis code indicating the purpose for the immunization. In ICD-10-CM, pediatricians simply report Z23 with each immunization. This simplifies the process and creates less work.

Diabetes (E08.- to E13.-)
The codes for diabetes have greatly expanded in ICD-10-CM to include the type of diabetes (i.e., type 1, type 2, drug- or chemical-induced, due to an underlying condition [specify the condition], or gestational) and any body systems affected and/or complications. An additional code is necessary to denote the use of insulin.

Underdosing (Z91.12- or Z91.13-)
Underdosing is a new concept in ICD-10-CM that captures instances in which a patient takes less of a medication than what is prescribed. Pediatricians must specify whether the underdosing is intentional or unintentional. If intentional, specify whether it’s due to financial hardship or some other reason. If unintentional, specify whether it’s because of an age-related debility or some other reason. Pediatricians may frequently report an intentional underdosing if parents cannot afford to provide medications for their children. These codes are important in terms of collecting data that insurers can use to provide programs to help individuals pay for medication or make suggestions for lower-cost drugs.

Injuries (various ICD-10-CM codes)
ICD-10-CM codes for injuries are organized by anatomical site. Pediatricians must document the site of the injury and the episode of care (i.e., initial, subsequent, or sequelae). When coding for injuries, it’s almost important to report external cause codes to explain how the injury occurred. These codes denote the following: External cause (i.e., how the injury was sustained), place of occurrence (i.e., where the injury occurred), activity (i.e., what the patient was doing at the time of the injury), and external cause status (i.e., work status of the patient at the time of the injury, such as work, volunteer, leisure activity, etc.).

Bronchitis (J20.-, J40-J42, J44.-, J47.0, J68.0)
Pediatricians must document acuity (i.e., acute, chronic, or subacute) as well as the causal organism (e.g., respiratory syncytial virus or metapneumoviris). If the cause of the bronchitis is unknown (as is often ultimately the case for patients with an initial presentation), it may be sufficient to report an unspecified code. Providers shouldn’t change their clinical decision-making process simply to obtain greater specificity. Providers should only perform a culture when warranted.

Feeding problems in newborn (P92.-)
Pediatricians must document the specific type of feeding problem (e.g., slow feeding, overfeeding, or regurgitation and rumination). Unlike ICD-9-CM, which only included two codes (779.34, failure to thrive, and 779.31, feeding problem), ICD-10-CM includes separate codes for each specific problem.

Strategies for success
Review each of the code categories listed above to familiarize yourself with code options. Also review CMS references for pediatricians. Laterality plays an important role for many of these diagnoses, and pediatric practices could take a significant financial hit if this information is not specified. And for more on how to manage the impact of ICD-10, download the free eBook, ICD-10 How to Transition Your Pediatric Practice now.

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