Documentation : Coding for Billing
To correctly code and bill pediatric child abuse cases, you need to understand the Current Procedural Terminology (CPT) published by the American Medical Association and the International Classification of Disease, Clinical Modification,10th Edition (ICD-10 CM) published by the World Health Organization. The CPT code tells the insurer "what" was done (i.e. type of visit), and the ICD-10 tells "why" or the diagnosis. See the Centers for Medicare & Medicaid Services (CMS) - ICD-10 Codes and the Centers for Disease Control and Prevention - National Center for Health Statistics, International Classification of Diseases, Tenth Revision (ICD-10).
In most office settings, the patient who presents with a child abuse issue or diagnosis is an "established patient." However, occasionally the suspected abuse patient may present as a "new patient" or even as a referral for consultation. Depending on whether the patient is new, established, or a consultation, separate CPT codes are used. In addition, when determining the level of evaluation and management (E&M level for CPT codes), the key components include the history, examination, and medical decision. However, if counseling and coordination of care drive 50% or more of the encounter, time determines the code for the visit.
Using a template that triggers coding for detailed or comprehensive histories and physicals may assist in the documentation process. There may be components of the evaluation that can utilize additional coding, such as prolonged visits, counseling, chart review, team conferences, continuing oversight, telehealth, and telephone calls.
E-codes
E-codes, or external codes of injury in child abuse cases, can be used to help describe the circumstances of an injury. E-codes are classified by:
- Intent (e.g., unintentional, homicide/assault, suicide/self-harm, undetermined)
- Mechanism (e.g., motor vehicle, fall, firearm, poisoning)
- Place of occurrence (e.g., playground)
- Activity (e.g., walking or running)
They essentially capture the “who, what, where, why and how” — further documenting the key features of the history. (See NC Detect - North Carolina Department of Health and Human Services - What are E-codes and why are they important?.)
ICD-Child Maltreatment codes are used to evaluate epidemiologic trends in abuse, clinical practices, and disparities (Rasooly IR, Khan AN, Aldana Sierra MC, Shankar M, Dang K, Cao L, Wood JN. Validating Use of ICD-10 Diagnosis Codes in Identifying Physical Abuse Among Young Children. Academic Pediatrics. 2023; 23 (2) : 396-401. (DOI) ). Studies have shown that diagnostic codes underestimate the true prevalence of child abuse diagnoses. (Lindberg DM. Bias and Objectivity When Evaluating Social Risk Factors for Physical Abuse: of Babies and Bathwater. The Journal of Pediatrics. 2018; 198 : 13-15. (DOI) ).
