Pediatric Coding Alert

Hint: Signs and symptoms codes may change, but the rules won’t.

It’s a common sight at pediatric visits—the patient comes in with a suspected diagnosis, but the pediatrician finds that the patient doesn’t actually have the illness in question, despite having symptoms. If you’re puzzled about how you’ll report this when ICD-10 hits, you can relax—because you’ll continue using the same signs and symptoms rules that you use now.

CMS aimed to eliminate confusion about this situation and other issues with its new MLN Matters article SE1518, which the agency issued on June 9. Fortunately for those readers who have the ICD-9 guidelines memorized, the rules won’t change considerably when it comes to signs and symptoms coding after Oct. 1.

“In both ICD-9-CM and ICD-10-CM, sign/symptom and unspecified codes have acceptable, even necessary, uses,” the article said. “While you should report specific diagnosis codes when they are supported by the available medical record documentation and clinical knowledge of the patient’s health condition, in some instances sign/symptoms or unspecified codes are the best choice to accurately reflect the health care encounter.”

In short: As you did with ICD-9, if the physician makes a definitive diagnosis by the end of the encounter, you’ll report that code. But if not, you should report the signs and symptoms that prompted the visit—for instance, code a sore throat if strep throat is suspected but the test results aren’t in. You’d report a code from the “unspecified” range for situations such as a patient who is diagnosed with pneumonia but the test results indicating the specific type haven’t come in yet, the article said.

Remember that if you do have a definitive diagnosis, you don’t need to report the signs and symptoms. For instance, if your patient has strep throat, you would report J02.0 (Streptococcal pharyngitis), but you wouldn’t include symptom codes for the associated throat pain or fever.

Check These 3 Pediatric Examples

You’ll list symptom codes when the physician hasn’t identified a definitive diagnosis. Symptom codes describe problems a patient is experiencing, so they come in handy when the cause is uncertain.

For example: A child has dysuria and a fever. Although a urine specimen is sent for culture, you don’t have a diagnosis yet and you don’t have the equipment to perform a dipstick screening test. 

In this case, you don’t have a more specific diagnosis so you should report the symptoms, which in this case will be dysuria (R30.0) and fever (R50.9) under ICD-10.

Example 2:  An 8-year-old comes in with a cough of three weeks and a low-grade fever. The pediatrician listens to the lungs and hears abnormal breath sounds, discovering that the patient has tachypnea. If the doctor prefers to base the diagnosis of pneumonia on lab results, he or she orders a chest x-ray. If the report comes back positive for pneumonia, the pediatrician can file the claim for the office visit with the pneumonia diagnosis (J18.9, Pneumonia, unspecified organism). 

If the film is normal or if you are still waiting for an interpretation of it, code the signs and symptom diagnoses: cough (R05), fever (R50.9) and tachypnea (R06.82). 

Example 3: A patient presents due to parental concern that the child has attention deficit disorder (ADD). The pediatrician reviews the information from the parent and examines the child, but does not feel comfortable making an ADD diagnosis without seeing reports from the teachers and/or school psychologists. 

In this case, the pediatrician will instead report the codes for the symptoms prompting the visit, such as R45.0 (Nervousness), R45.4 (Irritability and anger), R45.87 (Impulsiveness) and R45.86 (Emotional lability).

Resource: To read more about how to code signs and symptoms under ICD-10, see the MLN Matters article at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1518.pdf.