Pediatric Coding Alert

ICD-10 even includes choices for hard times.

Introduced to ICD-10 in 2015, the term "underdosing" is one you may not be fully familiar with.

But it's a concept you should know as, from time to time, pediatric practices will encounter patients and families undergoing financial difficulties.

This can lead them to "reduce the amount of medication needed to properly treat the child," according to Donelle Holle, RN, President of Peds Coding Inc., and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana.

"They just can't afford the medication," Holle states, creating an encounter similar to the following scenario that will help broaden your underdosing knowledge.

The Scenario

A 12-year-old boy with type 1 diabetes presents with blood sugar levels that are greatly elevated from previous visits. The pediatrician determines the patient has not been receiving a sufficient dose of insulin.

The patient's guardian then offers up the information that there has been a significant decrease in the household income due to unemployment, which has meant that the family has had to save money by decreasing the dosage of their medications to make them last longer.

Know What to Code and Why

You'll begin by coding the appropriate diagnosis code, such as E10.65 (Type 1 diabetes mellitus with hyperglycemia) along with an appropriate evaluation and management (E/M) service for the patient's present condition. But, Holle argues, this kind of scenario could well merit a lengthy additional E/M service, such as +99354-+99355 (Prolonged evaluation and management or psychotherapy service(s) (beyond the typical service time of the primary procedure) in the office or other outpatient setting requiring direct patient contact beyond the usual service ...), due to the level of counseling it involves.

"The pediatrician will need to discuss the importance of medication compliance with the family," Holle points out, adding that "they may also have to try to get help with medications." Coding +99354-+99355 would be appropriate, Holle believes, "and possibly 99358-+99359 (Prolonged evaluation and management service before and/or after direct patient care ...) due to so much work being done before or after the visit because of the complex nature of the scenario."  

To code the insulin underdose, however, you would go to the Z91.1 (Patient's noncompliance with medical treatment and regimen) codes in ICD-10. But once you get there, two very important notes await you.

The first is an Excludes1 note that states these codes exclude codes that describe any adverse reactions to prescription drugs that have been taken as directed and codes that describe poisoning or overdosing.

The second is a sequencing note that tells you to "Code first underdosing of medication (T36-T50) with fifth or sixth character 6."

Because of this, Chelle Johnson, CPMA, CPC, CPCO, CPPM, CEMC, AAPC Fellow, billing/credentialing/auditing/coding coordinator at County of Stanislaus Health Services Agency in Modesto, California, tells coders to go to external cause codes T38.3- (Poisoning by, adverse effect of and underdosing of insulin and oral hypoglycemic [antidiabetic] drugs) and indicate underdosing with the sixth character 6 and the seventh character A to indicate this is the patient's initial encounter for this condition, if that is indicated in your pediatrician's notes.

Once you have taken Johnson's advice and coded T38.3X6A (Underdosing of insulin and oral hypoglycemic [antidiabetic] drugs, initial encounter), you can then go back to the Z91.1 codes to provide the exact reason for the underdosing. To do this, you will have to find the answer to two significant questions in the note.

Ask, Is the Underdose Deliberate?

The Z91.1 codes are divided into several sections, indicated by fifth characters that document the underdosing is either deliberate (Z91.12), accidental (Z91.13), or not otherwise specified (Z91.14). For this scenario, as the underdosing is intentional, you would go with Z91.12, adding the appropriate sixth character 0 to indicate underdosing "due to financial hardship."

Additionally, Johnson notes, you then need to go ahead and code Z59.6 (Low income) to indicate the patient is experiencing "potential health hazards related to socioeconomic and psychosocial circumstances" per the language of ICD-10.

But What if the Underdose Is Accidental?

ICD-10 also allows for the possibility of the underdose being unintentional. Here, there is the same choice as you had with Z91.12, "for other reasons" indicated by the sixth character 8, and a sixth character 0 choice which leads you to Z91.130 (Patient's unintentional underdosing of medication regimen due to age-related debility).

This choice is unlikely, but not impossible, in the pediatric setting. You would expect to see it with elderly patients who might get confused over when to take a medication or how much of it to take. But it is conceivable that an adolescent patient may forget to take medications on a periodic basis, which could affect the therapeutic dosage adversely.

And What if the Underdose Isn't the Patient's Fault?

It is also important not to confuse the Z91.1 codes with Y63.6 (Underdosing and nonadministration of necessary drug, medicament or biological substance). This external cause of morbidity code indicates that it is the provider, not the patient, that has either not administered a drug, or has not administered the correct amount of a drug, to a patient, usually in a surgical setting.