The Health Insurance Portability and Accountability
Act (HIPAA) requires covered entities to adhere to the
most current International Classification of Diseases,
10th Revision, Clinical Modification (ICD-10-CM)
code set as well as ICD-10-CM guidelines.
It is important that the Academy be made aware of
payers that do not follow ICD-10-CM guidelines as
this is a direct HIPAA violation. It is equally important
for members to know the guidelines when reporting
A few guidelines are still causing confusion, and they
are addressed here.
The outpatient reporting rules state: “Do not code
diagnoses documented as “probable,” “suspected,”
“questionable,” “rule out,” or “working diagnosis” or
other similar terms indicating uncertainty. Rather, code
the condition(s) to the highest degree of certainty for
that encounter/visit, such as symptoms, signs, abnor-
mal test results, or other reason for the visit.”
This means you can never report a condition that
does not exist or you are clinically uncertain if it exists.
If the patient presents with signs or symptoms, you
would report those. If the patient is asymptomatic, you
must report a code from the “observation for suspected
conditions” categories Z03, Z04, Z05. Report a code
from these categories when a patient presents because
the parent believes the child has a condition, but after
further review, the condition does not exist.
Under injury reporting, 7th character “S,” sequela“is
for use for complications or conditions that arise as a
direct result of a condition, such as scar formation after
a burn. The scars are sequelae of the burn. When using
7th character “S,” it is necessary to use both the injury
code that precipitated the sequela and the code for the
sequela itself. The “S” is added only to the injury code,
not the sequela code. The 7th character “S” identifies
the injury responsible for the sequela. The specific type
of sequela (e.g., scar) is sequenced first, followed by
the injury code.”
The aftercare Z codes “should not be used for after-
care for conditions such as injuries or poisonings, where
7th characters are provided to identify subsequent care.
For example, for aftercare of an injury, assign the acute
injury code with the 7th character “D” (subsequent
A 1-year-old patient is seen in the office after a fall off the couch. The mom
was concerned about possible injuries.
None were noted, and the physician
documents “observation after fall, no
injuries.” The physician instructs the mom on what
to look for in case something develops, but at this
time the patient is fine. What ICD-10-CM code
should be reported?
You would report a code to show that the patient presented after an accident (fall), but no injuries or issues
were discovered. Z04.3 Encounter for examination and
observation following other accident
A patient is seen for recent onset of
headaches. The patient suffered a concussion three months prior but had
since been cleared and was doing OK.
There is no other known cause of the
headaches, so the physician notes that they are due
to the previous concussion. What ICD-10-CM
codes should be reported?
You would first list the sequela (headache) followed
by the original injury code with the 7th character for
S06.0X0S Concussion without loss of consciousness, sequela
A patient returns after having sutures placed in the right forearm. The
patient’s laceration has healed, and the
sutures are removed. What ICD-10-CM
code is reported?
This encounter is related to aftercare for an injury.
You will report the original injury code with 7th character “D” to denote that this is subsequent care for the
injury. Do not report any “aftercare codes.”
S51.811D Laceration without foreign body of right
forearm, subsequent encounter
A patient returns to his general surgeon to have dressings changed on a
recent procedure. What ICD-10-CM
code is reported?
This encounter is unrelated to an injury,
so the aftercare codes are applicable.
Z48.01 Encounter for change or removal of surgical
Becky Dolan, in the AAP Division of Health Care
Finance, contributed to this article.
• For more information on common ICD-10-CM issues,
see the November 2015 Coding Corner article “AAP
fields questions from members about ICD-10-CM,”
• Email coding questions to email@example.com.
• Learn how to simplify coding and billing by participating in the AAP Pediatric Coding Webinar series. Leading pediatric coding experts offer pediatric-specific
insights and strategies. Visit www.aap.org/webinars/
• Keep pace with the latest in coding with the monthly
AAP Pediatric Coding Newsletter. To view a sample
issue, visit www.coding.aap.org.
from the AAP Division of Health Care Finance
Manufacturers and retailers of pediatric acetaminophen solid dose medicines are transitioning
to a single strength of 160 milligrams (mg) to minimize medication errors and improve dosing compliance by reducing number of pills.
Currently, pediatric acetaminophen solid products are available in 80 mg and 160 mg strengths.
The 160 mg dosage strength aligns with the most
common single ingredient pediatric liquid acetaminophen concentration (160 mg/5mL).
The transition is consistent with 2011 recom-
mendations from a Food and Drug Administration
(FDA) advisory panel of outside experts, which pro-
posed that liquid, chewable and tablet forms of acet-
aminophen be made in just one strength. The FDA
has been working through the federal rulemaking
process to modify the over-the-counter monograph
to reflect these recommendations. In the interim, to
encourage safer use of these products, the agency has
established various communication mechanisms,
including an acetaminophen webpage and a guid-
ance document (see resources).
Manufacturers and retailers are voluntarily mov-
ing toward the single strength. For example, John-
son & Johnson Consumer Inc. recently announced
that it is transitioning its pediatric acetaminophen
solid dose, or chewables, to a single strength of 160
mg to be called “Children’s.”
Pediatric acetaminophen products on store
shelves can continue to be used as labeled.
Clinicians should encourage parents and caregivers to always check the label for the acetaminophen product strength (160 mg or 80 mg) before
Pediatric acetaminophen solid products
transitioning to single strength
• FDA acetaminophen webpage, http://bit.ly/2mxB16s
• FDA Over-the-Counter Pediatric Oral Liquid Drug Products Containing Acetaminophen Guidance for Industry,