Pediatric Coding Alert

Here are all the instructions and guidelines you need to make it through the season.

The temperatures are starting to drop, and your waiting room is beginning to get more and more crowded with sick kids coughing, sneezing, and sniffling. So, now would be a good time to refresh your knowledge of coding some of the more common winter conditions.

We’ve put together this collection of tips to help you navigate many of the ICD-10 instructions and guidelines that pertain to the Diseases of the Respiratory System codes. But be sure to read to the end, as we’ve also added a reminder about some new codes that you’ll be leaning on heavily in the next few months and beyond.

Tip 1: Obey the Lower Anatomic Site Note to J00-J99

One of the trickiest parts of coding respiratory system conditions is remembering the note at the beginning of ICD-10 Chapter 10 telling you that “when a respiratory condition is described as occurring in more than one site and is not specifically indexed, it should be classified to the lower anatomic site.” But you overlook the note at your peril because the note applies to all the codes in the section.

To avoid this particular coding error, your best bet is to refresh your knowledge of the respiratory system. If your pediatrician documents both nasopharyngitis and chronic pharyngitis, for example, knowing that the pharynx is anatomically lower in the system than the nasal passages will lead you to correctly code J31.2 (Chronic pharyngitis) on its own.

And don’t forget: “You need to add exposure to smoking,” cautions Donelle Holle, RN, president of Peds Coding Inc., and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana.

That’s because the entire J00-J99 code section also carries a Use additional code instruction telling you to use codes such as Z77.22 (Contact with and (suspected) exposure to environmental tobacco smoke (acute) (chronic)), F17.- (Nicotine dependence), or Z72.0 (Tobacco use) for any associated tobacco exposure, dependence, or use, Holle reminds coders.

Tip 2: Remember the Excludes1 Instructions for the J00-J06 Codes

Next, coding acute upper respiratory infections (J00-J06) comes with its own set of challenges in the form of the numerous Excludes1 instructions that accompany them.

First, there is one instruction that applies to all the J00-J06 that tells you to code J44.0 (Chronic obstructive pulmonary disease with (acute) lower respiratory infection) if a patient is diagnosed with both chronic obstructive pulmonary disease (COPD) and an acute lower respiratory infection along with one of the conditions from the group.

But there are also numerous Excludes1 instructions for many of the J00-J06 code subgroups, most notably the ones for J00 (Acute nasopharyngitis [common cold]). The instructions also include a lot of conditions that are typically seen with the common cold, especially a number of the pharyngitis codes such as acute pharyngitis (J02.-), and acute sore throat NOS (not otherwise specified), pharyngitis NOS, and sore throat NOS that all code to J02.9 (Acute pharyngitis, unspecified).

Tip 3: Look to Guideline I.C.10.c. for Influenza Probability

Coding for the J09.- (Influenza due to certain identified influenza viruses) and J10.- (Influenza due to other identified influenza virus) code groups is subject to another tricky, chapter-specific guideline that tells you to “code only confirmed cases of influenza.” The guideline goes on to tell you that confirmation “does not require documentation of positive laboratory testing specific for avian or other novel influenza A or other identified influenza virus.”

Instead, the guideline goes on to tell you that “coding should be based on the provider’s diagnostic statement that the patient has avian influenza, or other novel influenza A, for category J09, or has another particular identified strain of influenza, such as H1N1 or H3N2, but not identified as novel or variant, for category J10.” And for cases of influenza recorded by the provider as “‘suspected,’ ‘possible,’ or ‘probable,’” ICD-10 instructs you to assign an appropriate influenza code from category J11 (Influenza due to unidentified influenza virus).

What this means: This is one of those times when the chapter-specific guideline will override guideline IV.H, which instructs you not to “code diagnoses documented as ‘probable,’ ‘suspected,’ ‘questionable,’ ‘rule out,’ ‘compatible with,’ ‘consistent with,’ or ‘working diagnosis’ or other similar terms indicating uncertainty” when coding and reporting diagnoses in outpatient settings.

So, a patient reports to your pediatrician with fever, muscle pain, sore throat, earache, cough, and a runny nose. Your pediatrician documents that the patient has suspected influenza with otitis media. “Clinical judgment and experience are as valid as any test result for some conditions,” notes Jan Blanchard, CPC, CPEDC, CPMA, of Physician’s Computer Company in Winooski, Vermont. In this case, you would choose a code from J11, specifically J11.83 (Influenza due to unidentified influenza virus with otitis media) and use an additional code from H72.- (Perforation of tympanic membrane) for any associated perforated tympanic membrane.

Tip 4: Don’t Forget the New Cough Codes

Other codes that are sure to get a workout this winter are the new cough codes that are effective now. This newly expanded code group includes codes for different levels of severity, including:

• R05.1 (Acute cough)
• R05.2 (Subacute cough)
• R05.3 (Chronic cough)

Remember: you’ll use R05.3 if your pediatrician documents persistent cough, refractory cough (a cough that persists despite treatment), or unexplained cough, as ICD-10 has added all three as synonyms for this code.