ICD-10 Scenarios for Pediatrics

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

ICD-10 Clinical Scenarios for Pediatrics

• Scenario 1: Diarrhea, Fever, and Vomiting
• Scenario 2: Physical for Preschool Entrance
• Scenario 3: Asthma and Atopic Dermatitis
• Scenario 4: Newborn Feeding

Quality clinical documentation is essential for communicating the intent of an encounter, confirming medical necessity, and providing detail to support ICD-10 code selection. In support of this objective, we have provided outpatient focused scenarios to illustrate specific ICD-10 documentation and coding nuances related to your specialty.The following scenarios were natively coded in ICD-10-CM and ICD-9-CM. As patient history and circumstances will vary, these brief scenarios are illustrative in nature and should not be strictly interpreted or used as documentation and coding guidelines. Each scenario is selectively coded to highlight specific topics; therefore, only a subset of the relevant codes are presented.

The following scenarios were natively coded in ICD-10-CM and ICD-9-CM. As patient history and circumstances will vary, these brief scenarios are illustrative in nature and should not be strictly interpreted or used as documentation and coding guidelines. Each scenario is selectively coded to highlight specific topics; therefore, only a subset of the relevant codes are presented.

Pediatrics Clinical Scenarios

Scenario 1: Diarrhea, Fever, and Vomiting

Scenario Details

Chief Complaint

• Watery diarrhea, fever, and vomiting – 1 for 2 days.

History

• 33 month old female presents as new patient with severe dehydration after 2 days of watery diarrhea, fever and vomiting with no indication of nausea. Child holds onto stomach and is crying but makes no tears. Child unimmunized for all vaccines per mother2. Child noted to have reduced urine output per mother. Symptoms started after a visit to the pool with her cousins. Mother thinks daughter swallowed pool water multiple times.

Exam

• Apparent acute distress. Appears dehydrated. Child is holding her abdomen.
• Vitals: T 100.1, R 36, P 135 BP 90/55. BS hyperactive times four quadrants. The abdomen is distended and diffusely tender to palpation. No rebound tenderness, masses or organomegaly.
• Dry mouth and tongue, membranes pale. Skin dry with poor skin turgor.
• Capillary refill is >3 seconds.

Assessment and Plan

• Unvaccinated status a concern. Will address with family after this acute episode is over.
• Rotavirus likely. Order rotavirus with EIA and RT-PCR, electrolyte panel.
• Patient requires IV hydration. Send to hospital for IV fluids and observation. Admission orders called in.

Summary of ICD-10-CM Impacts

Clinical Documentation

1. Code the symptoms of diarrhea, fever, dehydration, dry mouth, and vomiting. Determine if the patient has nausea and document accordingly since there are codes to differentiate nausea and vomiting, and/or if there is the presence of vomiting without nausea.

2. Determine why the patient is not vaccinated and document accordingly. It is important to identify the reason(s) since there are multiple codes available to explain why immunizations haven’t been administered. Because this is a significant public health issue, ICD-10-CM has addressed the collection of this information by providing multiple coding explanations as to why a child has not been immunized. In this scenario, Z28.3 Under-immunization status is the most
   appropriate code as it represents delinquent in immunizations.

Coding

ICD-9-CM Diagnosis Codes

787.91 Diarrhea
780.60 Fever, unspecified 782.4 Jaundice NOS
787.03 Vomiting alone
276.51 Dehydration
789.67 Abdominal tenderness, generalized
V64.ØØ No vaccination, not otherwise specified

ICD-10-CM Diagnosis Codes

R19.7 Diarrhea, unspecified,
R50.9 Fever, unspecified
R11.11 Vomiting without nausea
E86.0 Dehydration
R10.817 Generalized abdominal tenderness
Z28.3 Under-immunization status

Other Impacts

No specific impacts noted.

Scenario 2: Physical for Preschool Entrance

Scenario Details

Chief Complaint

• Preschool physical

History

• 4 year old male presenting for preschool physical exam. No acute concerns1.
• Asthma2, child has albuterol inhaler. Average one attack a week, somewhat limiting in terms of physical play.
• Immunizations are up to date; none are due at this time.

Exam

• Child development normal for age. Vitals, height, and weight are normal. Height and weight in 95th percentile.
• All other physical exam body sections and organ systems are within normal limits.
• Asthma is usually well controlled. Parents are able to verbalize common triggers and understand how to limit or avoid common triggers.

Assessment and Plan

• Age-appropriate injury prevention and health promotion issues discussed.
• Reviewed sports and asthma status. The patient demonstrated correct use of albuterol inhaler. No side effects noted per mother.
• No immunizations due at this time; will continue to follow immunization schedule.
• School assessment documentation completed and a copy retained in the medical record.

Summary of ICD-10-CM Impacts

Clinical Documentation

1. There is an administrative requirement for a physical exam pertaining to educational institution admission; there is no complaint, suspected, or reported diagnosis is indicated in this scenario. Also, hearing and vision exams haven’t been performed. There are separate ICD-10-CM codes for vision screenings, hearing exams, and identified medical conditions; therefore, it is important to document this information in the patient’s record where applicable.

2. ICD-10-CM terminology used to describe asthma has been updated to reflect the current clinical classification system. The terms intrinsic and extrinsic are no longer used. Persistent asthma is now classified as mild, moderate or severe. Specific asthma triggers should be noted (and are described adequately here). Other causes for acute exacerbation or lack of responsiveness to bronchodilators are not documented here, but should be included and would be relevant for coding and billing. Persistence (acute, persistent, exercise induced, etc.), severity, frequency, and functional attributes should be noted to best reflect patient complexity of care. Since the primary focus of this visit is not asthma the level of documentation provided is sufficient.

Coding

ICD-9-CM Diagnosis Codes

V70.3 Medical exam not elsewhere classified, administrative purpose
493.00 Extrinsic asthma, unspecified

ICD-10-CM Diagnosis Codes

Z02.0 Encounter for examination for admission to educational institution
J45.20 Mild intermittent asthma uncomplicated

Other Impacts

Asthma is the most common chronic childhood illness and leading cause of pediatric hospitalization:

• Patient/parent adherence rates to medications and home-management recommendations may be low resulting in hospitalization and additional follow-up care which can be costly.
• There are HEDIS, Ambulatory Quality Alliance, and pay for performance measures (e.g., Leapfrog group) that may be applicable to this patient demographic group of your practice, depending on your payers.

Scenario 3: Asthma and Atopic Dermatitis

Scenario Details

Chief Complaint

• Asthma, atopic dermatitis.

History

• 6 year old male, established patient.

• Mother states son has had an exacerbation of asthma symptoms and observed a recent skin disruption during their family vacation to a dude ranch in Arizona last week. Mom stated that activities and issues associated with vacation may cause the asthma/skin disruption including potential allergens, change in sleep schedule, use of different laundry detergent, and exposure to new animals. She also mentioned there was significant second hand cigarette smoke exposure at the ranch with other guests and ranch employees.
• According to mother, child has asthma episodes about 2-3 times per month, effecting normal activities, but his condition is usually improved with short acting albuterol inhaler use. Child also has asthma episodes at nighttime occurring about once every three months.
• Several days prior to leaving the ranch, child began experiencing asthma episodes 2-3 times per day with difficulty in breathing, wheezing, and the feeling of heavy weight on his chest with progressive worsening. Mother states the albuterol inhaler was last used this morning, about 90 minutes prior to arrival, but seems less effective than usual.
• The skin disruption manifested three days after arrival to ranch; child’s mother describes this as a red, itchy, scaly rash noted on face with patches around mouth, on both hands, and inside both elbows.
• Vaccination status: up to date.
• Family medical history: positive for asthma in mother and father, no eczema, no allergies.

Exam

• Vital Signs: BP 110/67, HR 100, T 98.9°F, R 28, Wt. 25kg, SpO2 95%
• General appearance: mild respiratory distress, alert.
• ENT: oropharynx clear, no plaques or exudates, minimal nasal flaring noted, no accessory muscle use.
• Respiratory: diminished breath sounds with mild expiratory wheezing heard throughout.
• Cardiovascular: no murmurs, no rubs, no gallops.
• Gastrointestinal: soft, NT, ND, no organomegaly, + BS
• Skin: color of lips and fingernails normal; scratching, redness and irritated skin evident on face and both elbows with crusted red nail marks.
• All other systems within normal limits.

Assessment and Plan

• Intermittent asthma with acute exacerbation; atopic dermatitis. Asthma exacerbation caused by exposure to second-hand smoke.
• Administered one unit dose albuterol sulfate solution nebulizer treatment and first dose oral prednisolone in office with good response. Improvement noted.
• Prescribed 3-day course oral prednisolone; continue albuterol inhaler with spacer use as outpatient.
• Restart emollient cream applied after warm bath, and hydrocortisone cream applied to areas that itch.
• Discussed asthma action plan with mother, and when to call 911. Also discussed oral hygiene with use of inhaler.
• Mom instructed to return child in three days for recheck or sooner for worsening of symptoms.

Summary of ICD-10-CM Impacts

Clinical Documentation

1. ICD-10-CM uses the National Heart, Lung, and Blood Institute (NHLBI)’s asthma severity classification in the terminology. This information in the context of the NHLBI guidelines can be accessed at www.nhlbi.nih.gov/guidelines/asthma/asthma_qrg.pdf.
2. Wheezing and acute bronchospasm, if relevant, are integral to the underlying medical condition of asthma, and are thus not coded separately as symptoms.
3. ICD-10-CM has another change in reporting respiratory diagnoses such as asthma and has desires an additional code, where applicable, to identify whether the patient had exposure to second-hand smoke, a history of tobacco use, or current use or dependence of tobacco.
4. The assignment of this code for exposure to second hand smoke is dependent upon the physician’s documentation. The code should not be assigned as a first-listed diagnosis but may be assigned as an additional code when the physician has stated that second-hand smoke or environmental tobacco smoke is the cause of the patient’s condition. The code may not assigned in the absence of a condition or symptom.

Coding

ICD-9-CM Diagnosis Codes

493.92 Asthma, unspecified type, with (acute) exacerbation
691.8 Other atopic dermatitis and related conditions
V17.5 Family history of asthma
E869.4 Exposure to second hand smoke

ICD-10-CM Diagnosis Codes

J45.21 Mild intermittent asthma, with (acute) exacerbation
L20.9 Atopic dermatitis, unspecified
Z82.5 Family history of asthma and other chronic lower respiratory diseases
Z77.22 Contact with and (suspected) exposure to environmental tobacco smoke (acute) (chronic)

Other Impacts

No specific impact noted.

Scenario 4: Newborn Feeding

Scenario Details

Chief Complaint

• Feeding problem, vomiting, rash.

History

• 7 day old female newborn, established patient, last seen in hospital five days ago.
• Uncomplicated full term pregnancy, vaginal/forceps assisted.
• Intact family – mother, father, three siblings, all present with patient.
• Per parents, patient is not feeding well by breast or bottle. Baby does swallow, but feeds slow and only briefly. Dad reports baby never seems to experience pain before or after feedings. No real fussiness at meals.
• Dad states baby has about 1 milky-colored tablespoon of non-projectile vomiting at end of the feedings and this is sometimes followed with coughing. No vomiting occurs from mouth or nose when burping.
• Mom has tried different angles/positions for breast and bottle feeding – “I am not new to breastfeeding”. She states no issues with latching-on to breast and has tried feeding more frequently and for a shorter time. Mom denies consuming chocolate, coffee, peppermint, fatty foods, citrus fruit; no alcohol, drugs, or OTC medication use.
• Parents have started holding baby about 30 minutes in sitting or upright position after being fed. Baby currently feeding every 2 hours for 10 – 15 minutes, alternating breast and bottle with some improvement.
• Per mom, baby has about 6 – 7 wet diapers a day and usually 2 BMs per day. Stool is yellow and/or green in color and loose but not watery.
• Parents also notice a rash eruption on face about 4 days ago. They described rash as blotchy and looked like flea bites; there are no animals in household. Per parents, the rash shape and size is not consistent and seems to change every few hours.

Exam

• Vital Signs: Weight 6 lbs. 10.5 oz., decrease of 5.5 oz. from birth weight (~5% wt. loss). Length 19.5 inches. HR 148 bpm, T 98.1°F, R 42.
• General appearance: patient awake and alert, does not appear to be in pain.
• Head: Normocephalic, fontanelles normal.
• EENT: PERRLA, Ears normal. Nose clear. Palate is complete. Oropharynx is clear with moist mucous membranes, tongue normal.
• Neurological: Normal suck, grasp, + Babinski, and +Moro.
• Skin: Noted normal turgor. No jaundice noted. Erythema toxicum neonatorum noted. Several 2 mm macules, papules, pustules. Blotchy areas of erythema. Lesions on the face, trunk; no lesions on palms and soles.
• Gastrointestinal: Umbilical stump intact/dried, abdomen soft, without guarding & rebound, otherwise normal.
• Genitalia: Normal.
• Respiratory: Normal.
• Cardiovascular: Normal
• Joints: Negative for Barlow and Ortolani.
• All other systems within normal limits.

Assessment and Plan

• Difficulty feeding. Discussed additional feeding techniques, recommended adding nutritional supplements to breast milk to increase caloric intake. Supplements will include Vitamin D. Discussed introducing formula supplementation if symptoms continue.
• Instructed to watch for signs of dehydration.
• Will monitor for gastroesophageal reflux.
• Erythema toxicum neonatorum. Informed parents that rash should resolve on its own. Continue to watch.
• Next appointment in 2 days to recheck infant weight and feeding progress, sooner if symptoms worsen. Reminded parents of answering service/after hour’s number.

Summary of ICD-10-CM Impacts

Clinical Documentation

1. ICD-10-CM provides additional code selections to describe newborn feeding conditions. The new alternatives include difficulty feeding at breast, overfeeding, regurgitation and rumination, slow feeding, underfeeding, other feeding problems of newborn, and feeding problem of newborn, unspecified.
2. Newborn is defined as the first 28 days of life. If the condition first presents after 28 days, it is not considered a newborn condition. The newborn codes may be used throughout the life of the patient, if the condition was noted as present during the first 28 days of life, and if the condition remains present after 28 days.

Coding

ICD-9-CM Diagnosis Codes

779.31 Feeding problems in newborn
779.33 Other vomiting in newborn
778.8 Other specified conditions involving the integument of fetus and newborn

ICD-10-CM Diagnosis Codes

P92.2 Slow feeding newborn
P92.8 Other feeding problems of newborn (brief feedings)
P92.09 Other vomiting of newborn
P83.1 Neonatal erythema toxicum

Other Impacts

No specific impact noted.