Pediatric Coding Alert

Can you dispel these common warm-weather misconceptions?

The summer is filled with hot, lazy days — and certain misconceptions about pediatric coding that always spike when the mercury rises.

Help’s here: Check out these mythbusting facts on coding for patients who present with “summer” type conditions.

Myth 1: You Should Report 1 ICD-10-CM Code in Sunburn Cases

Reality: In fact, you would use several codes depending on the severity of the burn; the location of the burn, or burns, on the body; and the geographic location where the injury occurred.

As an example, consider the following scenario: A patient presents to your practice with a second-degree sunburn of the upper and lower back and shoulders a day after playing beach volleyball with friends.

You would begin with coding L55.1 (Sunburn of second degree), but the coding wouldn’t stop there. You would then report several codes from Chapter 19 to record the fact that the sunburn occurred on the patient’s back and shoulders:

• T21.23X (Burn of second degree of upper back)
• T21.24X (Burn of second degree of lower back)
• T22.251X (Burn of second degree of right shoulder)
• T22.252X (Burn of second degree of left shoulder)

Here, as Donelle Holle, RN, President of Peds Coding, Inc., and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana, points out, it is “important to remember to use the seventh-digit code to indicate an initial or subsequent visit, remembering that during the process of healing the visits are all initial.” So, you would add the seventh digit, A (initial encounter), to indicate that encounter.

The ICD-10-CM guidelines then require that you “use additional external cause code[s] to identify the source, place, and intent of the burn.” According to Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting, Inc. in Lansdale, Pennsylvania, these would include the following:

• X32.XXXA (Exposure to sunlight, initial encounter)
• Y93.68 (Activity, volleyball [beach] [court])
• Y92.832 (Beach as the place of occurrence of the external cause)
• Y99.8 (Other external cause status [Recreation or sport not for income or while a student])

Myth 2: West Nile Encounters Require a High Level of Service

Reality: In fact, according to Holle, coding a West Nile virus encounter this way could get you into a whole lot of trouble. “One of the worst mistakes to make is coding a 99215 [Office or other outpatient visitfor the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a comprehensive history; a comprehensive examination; medical decision making of high complexity …] with a viral syndrome,” Holle cautions. “This will likely get denied or, worse, paid at a lower level due to risk adjustment.”

The confusion, as Falbo sees it, comes from the fact that testing is needed to determine the virus’s exact diagnosis. She notes that “it is important for the provider to provide clear lab testing to determine the correct coding” and enable definitive reporting of either A92.30 (West Nile virus infection, unspecified) or A92.31 (West Nile virus infection with encephalitis). Even so, the virus’s presenting problems and the diagnostic procedures your pediatrician may order do not allow the level of risk to rise above minimal, according to the CMS 1997 guidelines for E/M services.

This would make the level of medical decision making (MDM) in West Nile cases straightforward at most. So, Holle concludes, “coders need to be aware of the MDM in these cases and alert the providers to be certain to document everything they are seeing, hearing and suspecting” before assigning a level of service to the encounter.

Myth 3: Poison Ivy Dx Coding Is Pain-Free

Reality: Actually, it’s a little more complicated than you think. First, there are as many as three ICD-10-CM codes that you could use: in addition to L23.7 (Allergic contact dermatitis due to plants, except food) and L24.7 (Irritant contact dermatitis due to plants, except food), Falbo notes that there is also L25.5 (Unspecified contact dermatitis due to plants, except food). “So, the origin of the poison ivy needs to be assessed,” Falbo explains.

Knowing the language of the descriptors will help you narrow down the diagnosis. L24.7 uses the word “irritant,” which means the dermatitis is localized, whereas L23.7 describes the condition as “allergic,” which Holle notes is an indication that “the poison ivy has spread and is now causing significant issues,” such as “infections on the skin.”

If this is the case, Holle points out that “coders will want to use as many diagnoses as possible if there are infections noted to help justify the level of care billed.” So, poison ivy coding isn’t exactly a walk in the park.