June 1, 2017
Knowing best practices for ICD-10 coding can help you avoid claim denials and payment delays. Mistakes involving patient age and age-related diagnosis codes are common. This type of mistake leads to an edit (“Diagnosis not typical for patient age”) and to denial.
In the ICD-10-CM system, some diagnosis codes specify age ranges. These age bands need to match the patient's age at the time of care. Here are some examples:
Newborn, child, and adolescent general exams: Z00 series diagnosis codes
Identical to the age ranges in the ICD-9-CM diagnoses for newborn, child, and adolescent general exams, these codes are broken out by the child's age, as stated in the code description itself. It's critical to match these ages to the patient's age on the date of service.
- Z00.110 - Health exam for newborn, under 8 days old
- Z00.111 - Health exam for newborn, 8-28 days old
- Z00.121 - Encounter for routine child health exam, child over 28 days old, with abnormal findings
- Z00.129 - Encounter for routine child health exam, child over 28 days old, without abnormal findings
Perinatal codes used on Maternal Claims: P00-P96 series diagnosis codes
Chapter 16 of the ICD-10-CM codebook (“Certain Conditions Originating in the Perinatal Period”) contains diagnoses to be used in the perinatal period, defined as before birth through the 28th day following birth. The codebook explains that these codes are only for newborn records, but we often see them on maternal claims.
The following examples should be submitted only on newborn claims:
- P92.5 - Neonatal difficulty in feeding at breast
- P92.8 - Other feeding problems newborn
- P92.9 - Feeding problem of newborn, unspecified
Body Mass Index (BMI): Z68 series diagnosis codes
ICD-10 CM expanded these codes into adult and pediatric BMI categories. The BMI number included in the code description is a weight/height calculation, but needs to be coded correctly for the patient's age, as described below.
BMI adult codes (Z68.1 through Z68.45) are used for persons 21 years of age or older:
- Z68.20 - Body Mass Index (BMI) 20.0-20.9, adult
- Z68.20 - Body Mass Index (BMI) 20.0-20.9, adult
BMI pediatric codes (Z68.51 - Z68.54) are used for persons 2-20 years of age. The percentiles noted in the code descriptions are based on growth charts published by the Centers for Disease Control and Prevention (CDC). An example is Z68.52 - Body Mass Index (BMI) pediatric, 5th percentile to less than 85th percentile for age.
We'll continue to edit for these age-to-diagnosis conflicts. To avoid future line or claim denials, review the official coding guidelines and information in the 2017 ICD-10-CM codebook or your coding applications.