encounter for well child visit with abnormal findings

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Chapter 1:  Well-Child Care

Sukanya Srinivasan; Donald B. Middleton

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Essentials of well-child care.

• COMPONENTS OF PREVENTIVE WELL-CHILD CARE
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Providing a comprehensive patient-centered medical home for children and assisting in the progressive transition to adulthood are integral components of family medicine. The provision of well-child care through a series of periodic examinations forms the foundation for the family physician to build lasting relationships with the entire family, a critical distinction between the family physician and other medical specialists.

Enhanced nutrition, mandated safety standards, and expanded schedules for immunizations have significantly improved the health of US children, but serious childhood health problems persist. Inadequate prenatal care leading to poor birth outcomes, poor management of developmental delay, childhood obesity, lack of proper oral health, and learning disabilities are some examples of ongoing issues.

A key reference guide for childhood health promotion is the third edition (currently in revision) of Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents , funded by the US Department of Health and Human Services. The guidelines give providers a comprehensive system of care that addresses basic concerns of child rearing such as nutrition, parenting, safety, and infectious disease prevention with focused attention on evidence-based health components and interventions.

One widely accepted schedule for routine well-child visits ( Table 1-1 ) is available in Bright Futures ( http://brightfutures.aap.org/clinical_practice.html ) (currently in revision). Seven visits are suggested during the first year, followed by an additional four visits by 2 years of age, and yearly visits until adulthood, coinciding with critical junctures during growth and development. Table 1-1 provides a structured framework for anticipatory guidance, exam features, and developmental screening recommendations at appropriate intervals.

The most important components of a preventive well-child visit include the following: (1) developmental/behavioral assessment; (2) physical examination, including measurement of growth; (3) screening tests and procedures; and (4) anticipatory guidance. The specific goal of each visit is to assess each component, identify concerns about a child’s development and intervene with early treatment, if available, or monitor closely for changes. Another essential, recognized component is adherence to the most recent schedule of recommended immunizations from the Advisory Committee on Immunization Practices (of the US Public Health Service) and the Centers for Disease Control and Prevention (ACIP/CDC) (see Chapter 7 ).

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The Well-Child Visit

• Original Investigation Adolescent Preventive Care and the Affordable Care Act Sally H. Adams, PhD; M. Jane Park, MPH; Lauren Twietmeyer, MPH; Claire D. Brindis, DrPH; Charles E. Irwin Jr, MD JAMA Pediatrics

Whatever name you use—check-up, well-child visit, or health supervision visit—these are important.

The benefits of well-child visits include tracking your child’s growth and development. Your pediatrician will review your child’s growth since the last visit and talk with you about your child’s development. These visits are a time to review and discuss each of the important areas of your child’s development, including physical, cognitive, emotional, and social development. Pediatricians often use a resource called Bright Futures to assess and guide discussions with parents about child development. Parents can access Bright Futures to review information relevant to their child’s age using the website at the bottom of this page.

Another benefit of a well-child visit is the opportunity to talk about prevention. For many children in the United States, the most common cause of harm is a preventable injury or illness. The well-child visit is an opportunity to review critical strategies to protect your child from injury, such as reviewing car seat use and safe firearm storage. The well-child visit is an opportunity to ensure your child is protected from infectious diseases by reviewing and updating his or her immunizations. If there is a family history of a particular illness, parents can discuss strategies to prevent that illness for their child. Healthy behaviors are important to instill at a young age, and the well-child visit is a time to review these important behaviors, such as sleep, nutrition, and physical activity.

During the teenage years, well-child visits offer adolescents an opportunity to take steps toward independence and responsibility over their own health behaviors. Every well-child visit with a teenager should include time spent alone with the pediatrician so that the adolescent has the opportunity to ask and answer questions about their health. Adolescent visits provide an opportunity for teenagers to address important questions, including substance use, sexual behavior, and mental health concerns.

Physical examination and screening tests are also a part of the well-child visit. Your child’s visit may include checking blood pressure level, vision, or hearing. Your pediatrician will do a physical examination, which may include listening to the lungs and feeling the abdomen. Screening tests can include tests for anemia, lead exposure, or tuberculosis. Some screening, such as for depression or anxiety, is done using a paper form or online assessment.

How Parents and Kids Can Get the Most Out of a Well-Child Visit

Ideally, schedule the visit ahead of time so that there is time to complete any required school or sports forms. Some parents schedule these visits to correspond with their children’s birthdays, while others schedule these during summer months to prepare for the start of a new school year.

Make a list of topics you want to discuss with your child’s pediatrician, such as development, behavior, sleep, eating, or prevention. Bring your top 3 to 5 questions with you to the visit. As your child gets older, ask your child to contribute any questions he or she would like to ask.

When going to the visit, it may be helpful to bring your child’s immunization record, a list of questions, or any school or sports forms you need completed.

For More Information

https://www.healthychildren.org/English/family-life/health-management/Pages/Well-Child-Care-A-Check-Up-for-Success.aspx .

Published Online: November 6, 2017. doi:10.1001/jamapediatrics.2017.4041

Conflict of Interest Disclosures: None reported.

See More About

Moreno MA. The Well-Child Visit. JAMA Pediatr. 2018;172(1):104. doi:10.1001/jamapediatrics.2017.4041

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ICD-10-CM: Immunization at Well-Child Encounter

Icd-10-cm: examination after house fire, icd-10-cm: accelerated growth in head circumference, answers to your questions on icd-10-cm coding.

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American Academy of Pediatrics; Answers to Your Questions on ICD-10-CM Coding. AAP Pediatric Coding Newsletter February 2016; 11 (5): 2. 10.1542/pcco_book142_document002

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When reporting immunizations administered at the time of a well-child visit, is it necessary to report code Z23 or is the diagnosis for well-child visit (Z00.129) sufficient?

Both codes are reported. International Classification of Diseases, 10th Revision, Clinical Modification ( ICD-10-CM ) includes a “code first” instruction at code Z23 (encounter for immunization) advising that the code for the well-child visit (eg, Z00.129 , encounter for routine child health examination without abnormal findings) is the first-listed code. Code Z23 is additionally reported. Code Z23 may also be reported for immunization at encounters other than a well-child visit.

I saw 2 children in the office the day after they had a fire in their house that filled the house with smoke before anyone woke up. The fire department came and cleared the smoke. Later that day, one of the children developed cough, fever, vomiting, and runny nose. I diagnosed that child with an upper respiratory infection unrelated to the smoke exposure. The other child was checked because of the exposure to the smoke and had absolutely no symptoms (not even a cough) and no abnormal findings. What   ICD-10-CM   codes are appropriate for this encounter?

ICD-10-CM codes that represent the diagnoses for the child with the upper respiratory infection and exposure to smoke in the house fire would be as follows:

ICD-10-CM codes for the child who was examined and found to have no effect from the exposure to smoke would be as follows:

Code Z04.3 is appropriate for this child’s encounter because the child presented without signs or symptoms and abnormality due to smoke exposure was ruled out. A note at category Z04 provides direction in reporting encounters for examination and observation that result in ruling out an abnormal condition.

This category is to be used when a person without a diagnosis is suspected of having an abnormal condition, without signs or symptoms, which requires study, but after examination and observation, is ruled-out. This category is also for use for administrative and legal observation status.

We have some newborns whose head circumference seems to be growing a little faster than normal, although not diagnosed as macrocephaly. Can you suggest codes for reporting abnormal velocity of head circumference?

Because the question notes newborns whose head circumference is growing faster than normal, code P96.89 , other specified conditions originating in the perinatal period, is the most specific code for this finding. If this is an abnormal finding at a newborn preventive medicine encounter, code Z00.110 , health examination for newborn under 8 days old, or Z00.111 , health examination for newborn 8 to 28 days old, would be the first-listed diagnosis. For finding of accelerated increase in head circumference without diagnosis of macrocephaly after the child is no longer a neonate, see code R68.89 , other general symptoms and signs, and, when applicable, code Z00.121 , encounter for routine child health examination with abnormal findings.

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Test your knowledge of ICD-10 coding and documentation requirements for five diagnoses you're likely to encounter in family medicine.

CINDY HUGHES, CPC, CFPC

Fam Pract Manag. 2015;22(5):15-21

Author disclosure: no relevant financial affiliations disclosed.

The time has come. Are you ready for the Oct. 1 transition to ICD-10 diagnosis coding? If you are not sure, you are not alone. Many elements of this transition have depended on your software vendors, clearinghouses, payers, and staff, but there is one thing you can control: your documentation of the information necessary to support the diagnosis codes you choose to bill. Your documentation probably does not need a major overhaul, but you will need to be more specific and detailed in certain areas. In this article, we will look at the documentation elements required to support ICD-10 code selection, focusing on five common conditions in family medicine. Quizzes will test your knowledge throughout the article.

First, why should you care?

The increased specificity required in your documentation and coding under ICD-10 may seem unnecessarily burdensome. However, diagnosis coding has a wider impact than you might immediately recognize.

Question: In which of the following ways does diagnosis coding affect physician practices and patient care?

Diagnosis codes support the medical necessity of services provided.

Diagnosis codes support claims payment.

Diagnosis data is increasingly used to evaluate cost and quality of care.

Diagnosis data is used to influence public health policy.

All of the above.

Answer: The diagnosis codes reported on physician claims must be supported not only to facilitate payment but also because they become the data upon which decisions beyond claims payment are made. The correct answer to the above question, then, is E, all of the above.

Documentation that supports specific diagnosis coding also may alleviate burdensome medical record requests from third parties. Take for instance the following statement a physician forwarded to me from a claims administrator regarding medical record requests to support risk adjustment: “ICD-9-CM (or its successor ICD-10-CM) diagnosis codes determine a patient's risk score. The more diagnosis detail submitted with claims and encounters, the less likelihood that [insurer name redacted] will need to request and audit medical records.” In other words, if your documentation supports the level of service coded and the selected diagnosis codes specifically identify the nature of your patient's condition, you are less likely to receive a request for your medical record. If a request is made, your documentation will support both the service provided and why it was provided.

DOCUMENTATION ELEMENTS FOR COMMON DIAGNOSES

This article contains seven tables outlining the documentation elements for common diagnoses. All seven tables are available for download as a single resource.

What to report

Before we review common diagnoses, it is important to know when codes should and should not be reported for a condition.

Question: According to the official guidelines for ICD-10, which of the following conditions should be reported?

All conditions listed in the problem list.

Only conditions with confirmed and differential diagnoses.

All conditions that require or affect patient care or treatment at the time of the encounter.

Only the condition related to the chief complaint.

Conditions that are probable.

Answer: The ICD-10 guidelines (like ICD-9) specify that physicians should not report the following:

Conditions documented as probable, likely, or to be ruled-out (rules differ for facilities),

Codes for symptoms that are integral to an established diagnosis,

Conditions that are no longer present,

Conditions that did not affect management or treatment at the current encounter.

Therefore, the answer to the question is C. All conditions that require or affect patient care or treatment at the time of the encounter should be reported. Physicians should list first the condition that is chiefly responsible for the services provided and code what is known at the time of the encounter.

This instruction to code what is known at the time of the encounter is important. Based on this guideline, physicians should report unspecified codes such as J12.9, unspecified viral pneumonia, when the information known at the time of the encounter does not support a more specific diagnosis. The guidelines state, “It would be inappropriate to select a specific code that is not supported by the medical record documentation or conduct medically unnecessary diagnostic testing in order to determine a more specific code.”

Other important documentation guidelines include the following:

List first a disease and then associated manifestations,

Link sequelae (late or residual conditions) to the history of an injury or past medical condition,

Report personal or family history codes when the history affects care or influences treatment.

Five common diagnoses

With so many diagnoses in primary care, it makes sense to focus your ICD-10 education efforts on those that are common in your specialty. The National Center for Health Statistics provides this data. 1

Question: Which condition is the top reason for office or other outpatient visits to family physicians?

Hypertension.

Otitis media.

Well-child examinations.

Answer: All of the above conditions are near the top of the list for family medicine, but for the number one diagnosis, you'll have to read on. Let's take a look at five commonly reported diagnoses and their documentation requirements under ICD-10.

Number five: asthma

Asthma classification in ICD-10 mirrors the guidelines from the National Asthma Education and Prevention Program, which differs from ICD-9. 2

Question: Which of the following is not an option for the classification of asthma in ICD-10?

Mild intermittent.

Mild persistent.

Moderate persistent.

Severe persistent.

Answer: All of the above classifications are options in ICD-10 except A, intrinsic. That was the old terminology used in ICD-9.

Note: Personal risk factor codes, such as Z91.14, “Patient's other noncompliance with medication regimen,” may be added to indicate poor compliance and explain any complications.

If you were to document asthma without specifying the classification or status, that would be reported with code J45.909, unspecified and uncomplicated asthma. However, consider the implications of reporting J45.909 for a patient who is not compliant with control medications, is seen for an acute exacerbation, and requires a revised care plan. This code not only fails to identify the nature of the patient presentation but also fails to convey the assessment of the asthma status and the complicating factor of noncompliance. Documenting a bit more detail – moderate persistent asthma with exacerbation, J45.41 – better conveys the nature of the encounter. Code Z91.14 could be added to specify the patient's poor compliance with control medication and explain the patient management complications.

Number four: otitis media

Both ICD-9 and ICD-10 provide codes to specifically identify otitis media as acute or chronic and as serous, allergic, or suppurative. Despite the availability of more specific codes, ICD-9 code 382.9 (unspecified otitis media) was frequently reported. Use of an unspecified code is appropriate when no further information is known at the time of the encounter; however, more specific reporting is appropriate when further information is known, and it typically better supports the level of service rendered.

Question: Specific reporting of otitis media includes which of the following documentation elements?

Type (e.g., serous).

Laterality (e.g., left).

Occurrence (e.g., chronic).

Tympanic membrane status (e.g., ruptured).

Number three: diabetes

*Type 2 is the default if type is not documented.

Question: Which of the following documentation elements would be required to accurately code an encounter with a patient who has diabetes, loss of protective sensation, a foot ulcer, and an elevated A1C result?

Type of diabetes.

Location of the ulcer.

Related conditions (manifestations).

Condition status/characteristics (e.g., uncontrolled).

(For more information on documenting diabetes in ICD-10, see “ Getting Ready for ICD-10: How It Will Affect Your Documentation ,” FPM , November/December 2013.)

The following codes would be reported to describe care of a patient with poorly controlled diabetes, loss of protective sensation, and diabetic ulcer of the left great toe with the fat layer exposed:

E11.65, diabetes type 2 with hyperglycemia,

E11.40, diabetes type 2 with neuropathy,

E11.621, diabetic foot ulcer,

L97.502, ulcer left foot, toe, fat layer exposed.

Note that codes for type 2 diabetes are reported even though the documentation did not specify the type of diabetes. This is because the guidelines instruct that type 2 is the default when documentation does not specify the type. Also, the ICD-10 index includes subterms for inadequately controlled and poorly controlled diabetes that direct physicians to report diabetes by type with hyperglycemia.

Number two: well-child examinations

The second-most common diagnosis is the well-child visit. Documentation for this encounter requires two elements. The first is the age of the child.

Question: What is the second element you would need to document for a well-child visit for ICD-10?

Whether the examination resulted in abnormal findings.

Whether the patient is new.

Established conditions from the problem list.

Suspected conditions.

Symptoms related to an established diagnosis.

Answer: Aside from the age of the child, the other element you would need to document for ICD-10 is whether the examination resulted in abnormal findings – answer A. New in ICD-10 are separate codes for routine child health examinations with abnormal findings (Z00.121) or without abnormal findings (Z00.129). Even if an abnormal finding does not merit a separately identifiable evaluation and management service, if it requires future surveillance it should be reported as an additional diagnosis. Report Z00.121 as the first code and then add the code for the finding.

Similarly, routine adult health and gynecological examinations are reported based on the presence or absence of abnormal findings; see codes Z00.00-Z00.01 and Z01.411-Z01.419.

As with ICD-9, ICD-10 includes separate codes for reporting examinations of newborns less than 8 days old and newborns 8 days to 28 days old. These codes do not identify the presence or absence of abnormal findings:

Z00.110 Health examination for newborn under 8 days old,

Z00.111 Health examination for newborn 8 to 28 days old.

(See “ Table five: Documentation elements for well-child visits .”)

And the number one diagnosis is…

Hypertension is the condition most often reported as the reason for an ambulatory care encounter in family medicine.

Question: Which of the following are options for the classification of hypertension in ICD-10?

Unspecified.

Uncomplicated.

None of the above.

Answer: Under ICD-9, physicians were challenged to classify hypertension as benign, malignant, or unspecified. This is simplified in ICD-10 with a single code, I10, for reporting hypertension, whether described as benign, malignant, or simply essential hypertension. The answer to the above question, then, is E, none of the above. However, coding for hypertensive conditions such as hypertensive heart or kidney disease can be more specific. Key documentation guidelines for these conditions include the following:

Categories I11, I12, and I13 include combination codes that describe hypertensive heart disease with or without heart failure, hypertensive chronic kidney disease, and hypertensive heart and chronic kidney disease. (See “ Table six: Documentation elements for hypertensive diseases .”)

The causal relationship between hypertension and heart disease must be documented (e.g., due to hypertension or hypertensive). If documentation does not indicate hypertension as a cause of the heart disease, separate codes for hypertension and the specified heart condition must be reported.

An additional code from category I50 must be assigned to identify the type of heart failure in patients with hypertensive heart disease with heart failure.

Unlike hypertension with heart disease, a cause-and-effect relationship is presumed for hypertension with chronic kidney disease. Report hypertensive chronic kidney disease when both diseases are present.

Codes in category N18 are reported in addition to the code for hypertensive chronic kidney disease to indicate the stage of the disease.

To further illustrate these documentation elements, consider a patient for whom you have made the following assessment: hypertension and left ventricular hypertrophy. Codes assigned for this encounter would be I10 for hypertension and I51.7 for cardiomegaly. However, if your assessment was hypertension and hypertensive left ventricular hypertrophy, code I11.9 would be assigned for hypertensive heart disease without heart failure.

(For more information on documenting hypertension in ICD-10, see “ How to Document and Code for Hypertensive Diseases in ICD-10 ,” FPM , March/April 2014.)

Beyond the top five

Several common documentation elements support better coding for conditions beyond just the top five diagnoses. These elements – type, location, occurrence, characteristics, and related conditions – are listed with examples of each in “ Table seven: Common documentation elements .” As you review the table, consider how each element might be applied to diagnoses that you frequently manage.

Don't panic

It may take a while to gain proficiency and gather resources to help you document and select ICD-10 codes that appropriately report the conditions you are managing. Acknowledging this, the Centers for Medicare & Medicaid Services and the American Medical Association recently announced a one-year grace period during which Medicare claims will not be denied solely because the diagnosis code is not specific enough – as long as it is from the appropriate family of ICD-10 codes (the three-character category) and is a valid code.

As you become more familiar with the codes, work toward greater specificity and accuracy, and look for ways to improve your coding and documentation processes and systems. For example, you might ask your electronic health record vendor about creating a “favorites” list of ICD-10 codes. Just remember that this time of transition will pass, but adopting better documentation and coding habits that capture the true nature of the conditions you manage and the quality of care you provide will be to your advantage as heath care transitions from fee-for-service to value-based payment.

ARTICLES IN FPM'S ICD-10 SERIES

You can access the following articles in FPM 's ICD-10 topic collection :

" ICD-10: Major Differences for Five Common Diagnoses ," FPM , September/October 2015.

" ICD-10 Sprains, Strains, and Automobile Accidents ," FPM , May/June 2015.

" Digesting the ICD-10 GI Codes ," FPM , January/February 2015.

" Coding Common Respiratory Problems in ICD-10 ," FPM , November/December 2014.

" ICD-10 Simplifies Preventive Care Coding, Sort Of ," FPM , July/August 2014.

" ICD-10 Coding for the Undiagnosed Problem ," FPM , May/June 2014.

" How to Document and Code for Hypertensive Diseases in ICD-10 ," FPM , March/April 2014.

" 10 Steps to Preparing Your Office for ICD-10 – Now ," FPM , January/February 2014.

" Getting Ready for ICD-10: How It Will Affect Your Documentation ," FPM , November/December 2013.

" The Anatomy of an ICD-10 Code ," FPM , July/August 2012.

" ICD-10: What You Need to Know Now ," FPM , March/April 2012.

National Ambulatory Medical Care Survey, 2009. Hyattsville, MD: National Center for Health Statistics; 2011.

National Asthma Education and Prevention Program. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. Bethesda, MD: National Heart, Lung, and Blood Institute; 2007.

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