Pediatric Coding Alert

How well do you know the Chapter 21 codes?

Once you’ve answered the quiz questions on page 3, compare your answers with the ones provided below:

Answer 1: Even though your provider has not documented the father’s active military status, you can still go ahead and code Z63.31 (Absence of family member due to military deployment).

That’s because “social determinants of health [SDOH], such as information found in codes Z55-Z65 [Persons with potential health hazards related to socioeconomic and psychosocial circumstances] ‘may be based on medical record documentation from clinicians involved in the care of the patient who are not the patient’s provider since this information represents social information, rather than medical diagnoses,’” says Donna Walaszek, CCS-P, billing manager, credentialing/ coding specialist for Northampton Area Pediatrics, LLP, in Northampton, Massachusetts, quoting ICD-10 guideline B.14.

Teachable moment: “In a perfect world, the coder would advise and educate the provider to addend their note to indicate the reason for absence. Identifying this in the documentation may contribute to the risk of complication and/or morbidity and mortality of patient management element of medical decision making [MDM] as an identified SDOH,” Walaszek advises.

Answer 2: As all the encounters occurred in the hospital in which the baby was born, ICD-10 guideline 1.C.16.a.2 tells you that “a code from category Z38 [Liveborn infants according to place of birth and type of delivery] [should be] assigned … once, to a newborn at the time of birth.”

In other words, “for attending physician services, a code from this category can be reported as first listed every time the physician visits the newborn during the birth admission,” Walaszek notes. So, you would use Z38.00 (Single liveborn infant, delivered vaginally) in this encounter for any neonatal care up to discharge from the hospital where the baby is born.

This also means you should not use Z00.110 in this encounter as the patient received all her care in the hospital before being discharged.

Answer 3: For so-called “worried well” or “feared well” scenarios, where a patient does not receive a diagnosis, or the provider records no signs or symptoms in the medical record, you can use either Z03.89 (Encounter for observation for other suspected diseases and conditions ruled out) or Z71.1 (Person with feared health complaint in whom no diagnosis is made). And even though “worried well” is a synonym for Z71.1, there are important, subtle differences between the codes that you should bear in mind before assigning one or the other.

The Z03 codes are to be used “when a person without a diagnosis is suspected of having an abnormal condition, without signs or symptoms, which requires study — but after examination and observation, is ruled out,” according to ICD-10. This means the code is more appropriate for situations when there is reason to suspect the child may have a condition, but the provider needs to wait to make a definitive determination on the patient’s condition.

The Z71 codes, however, are used for “persons encountering health services for other counseling and medical advice, not elsewhere classified,” also according to ICD-10 guidelines. This means your use of Z71.1 implies that the care was more to reassure the parent and reduce caregiver anxiety.

Be careful: Most, if not all, payers will not reimburse for Z71.1. The best code to use in this situation is Z03.89, as a pediatric patient will present with something the parent believes could be a problem, but the pediatrician will make the determination that the patient does not have any issues after doing a history and exam.

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