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The clinical concepts for pediatrics guide includes common ICD-10 codes, clinical documentation tips and clinical scenarios.

ICD-10 Clinical Documentation Tips for Pediatrics

  • Asthma
  • Underdosing
  • Diabetes Mellitus, Hypoglycemia and Hyperglycemia
  • Injuries
  • Well Child Exams and Screening
  • Otitis Media
  • Bronchitis and Bronchiolitis
  • Feeding Problems of the Newborn

Specifying anatomical location and laterality required by ICD-10 is easier than you think.

This detail reflects how physicians and clinicians communicate and to what they pay attention. It is a matter of ensuring the information is captured in your documentation.

In ICD-10-CM, there are three main categories of changes:

  • Definition Changes
  • Terminology Differences
  • Increased Specificity

For pediatrics the focus is on increased specificity. Over 1/3 of the expansion of ICD-10 codes is due to the addition of laterality (left, right, or bilateral). Physicians and other clinicians likely already note laterality when evaluating the clinically pertinent anatomical site(s).


Terminology Difference

ICD-10 terminology used to describe asthma has been updated to reflect the current clinical classification system.

When documenting asthma, include the following:

  1. Cause – Exercise induced, cough variant, related to smoking, chemical or particular cause, occupational
  2. Severity – Choose one of the three options below for persistent asthma patients
  • Mild persistent
  • Moderate persistent
  • Severe persistent
  1. Temporal Factors
  • Acute
  • chronic
  • intermittent
  • persistent
  • status asthmaticus
  • acute exacerbation

ICD-10 Code Examples

J45.30 Mild persistent asthma, uncomplicated
J45.991 Cough variant asthma


Terminology Difference

Underdosing is an important new concept and term in ICD-10. It allows you to identify when a patient is taking less of a medication than is prescribed.

When documenting underdosing, include the following:

  1. Intentional, Unintentional, Non-compliance Is the underdosing deliberate? (e.g., patient refusal)
  2. Reason Why is the patient not taking the medication? (e.g. financial hardship, age-related debility)


Increased Specificity

The diabetes mellitus codes are combination codes that include the type of diabetes mellitus, the body system affected, and the complications affecting that body system.

When documenting underdosing, include the following:
1. Type e.g. Type 1 or Type 2 disease, drug or chemical induces, due to underlying condition, gestational
2. Complications What (if any) other body systems are affected by the diabetes condition? e.g. Foot ulcer related to diabetes mellitus
3. Treatment Is the patient on insulin?

A second important change is the concept of “hypoglycemia” and “hyperglycemia.” It is now possible to document and code for these conditions without using “diabetes mellitus.” You can also specify if the condition is due to a procedure or other cause.
The final important change is that the concept of “secondary diabetes mellitus” is no longer used; instead, there are specific secondary options.

ICD-10 Code Examples

Z91.120 Patient’s intentional underdosing of medication regimen due to financial hardship
T36.4x6A Underdosing of tetracyclines, initial encounter
T45.526D Underdosing of antithrombotic drugs, subsequent encounter


Increased Specificity

ICD-9 used separate “E codes” to record external causes of injury. ICD-10 better incorporates these codes and expands sections on poisonings and toxins.

When documenting injuries, include the following:

  1. Episode of Care e.g. Initial, subsequent, sequelae
  2. Injury site Be as specific as possible
  3. Etiology How was the injury sustained (e.g. sports, motor vehicle crash, exposure?)
  4. Place of Occurence e.g. School, work, etc.

Initial encounters may also require, where appropriate:

  1. Intent e.g. Unintentional or accidental, self-harm, etc.
  2. Status e.g. Civilian, military, etc.

ICD-10 Code Examples

E08.65 Diabetes mellitus due to underlying condition with hyperglycemia
E09.01 Drug or chemical induced diabetes mellitus with hyperosmolarity with coma
R73.9 Transient post-procedural hyperglycemia
R79.9 Hyperglycemia, unspecified

Example 1:

A left knee strain injury that occurred on a private recreational playground when a child landed incorrectly from a trampoline:

ICD-10 Code Examples

  • Injury: S86.812A, Strain of other muscle(s) and tendon(s) at lower leg level, left leg, initial encounter


Increased Specificity

ICD-10 will improve the quality of data collection for well child exams, early screening, and the detection of childhood illnesses.
When documenting well child exams and screen, include the following:

  1. Child’s age In days, months or years as appropriate
  2. Exam type e.g. Well child exam, hearing screen, sports physical, school physical, etc.
  3. Findings Note normal vs. abnormal findings, as there codes vary depending on results
  • External cause: W09.8xxA, Fall on or from other playground equipment, initial encounter
  • Place of occurrence: Y92.838, Other recreation area as the place of occurrence of the external cause
  • Activity: Y93.44, Activities involving rhythmic movement, trampoline jumping

Example 2:

On October 31st, Kelly was seen in the ER for shoulder pain and X-rays indicated there was a fracture of the right clavicle, shaft. She returned three months later with complaints of continuing pain. X-rays indicated a nonunion. The second encounter for the right clavicle fracture is coded as S42.021K, Displaced fracture of the shaft of right clavicle, subsequent for fracture with nonunion.

ICD-10 Code Examples

Z00.129 Encounter for routine child health examination without abnormal findings
Z00.121 Encounter for routine child health examination with abnormal findings
Z00.110 Newborn check under 8 days old
Z00.111 Newborn check 8 to 28 days old


Increased Specificity

When documenting otitis media, include the following:

  1. Type e.g., Serous, sanguinous, suppurative, allergic, mucoid
  2. Infectious agent e.g., Strep, Staph, Scarlett Fever, Influenza, Measles, Mumps
  3. Temporal factors Acute, subacute, chronic, recurrent
  4. Side e.g. Left, right or both ears
  5. Tympanic Membrane Rupture Note whether this is present
  6. Secondary causes e.g. Tobacco smoke, etc.

ICD-10 Code Examples

H66.001 Acute suppurative otitis media without spontaneous rupture of ear drum, right ear
H66.004 Acute suppurative otitis media without spontaneous rupture of ear drum, recurrent, right ear
H65.03 Acute serous otitis media, bilateral
H72.821 Total perforations of the tympanic membrane, right ear


Increased Specificity

When documenting bronchitis and bronchiolitis, include the following:

  1. Acuity e.g., Acute, chronic, subacute. Delineate when both acute and chronic are present, e.g., acute and chronic bronchitis
  2. Causal Organism e.g. Respiratory syncytial virus, metapneumoviris, unknown, etc.

ICD-10 Code Examples

J20.2 Acute bronchitis due to streptococcus
J21.0 Acute bronchiolitis due to respiratory syncytial virus
J21.1 Acute bronchiolitis due to human metapneumovirus


Increased Specificity

In ICD-10-CM, newborn remains defined as the first 28 days of life.

Document feeding problems of the newborn and subsequent treatment recommendations specifically in your note.

Example issues with discrete ICD-10 coding options include:

  1. Difficulty feeding at breast
  2. Slow feeding
  3. Underfeeding
  4. Overfeeding
  5. Regurgitation and rumination

ICD-10 Code Examples

P92.1 Regurgitation and rumination of newborn
P92.2 Slow feeding of newborn
P92.5 Neonatal difficulty in feeding at breast