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Pediatric Coding Alert

Case Study Corner:

Can You Code This Fetal Alcohol Syndrome Case Study?

Don’t forget to factor in prolonged care time.

A 6-month-old patient presents to your provider with her parents. Her height and weight are below the tenth percentile of her age group, and her parents have observed cognitive delays, balance and coordination problems, poor muscle tone, and problems with fine motor skills. The patient also has difficulty sleeping and feeding.

On examination, the provider notes the patient has three different dysmorphic facial features: a short palpebral fissure (the horizontal distance between the eyelids, or the distance between the endocanthion and exocanthion, measured at or below the tenth percentile), a smooth philtrum (the absence of a vertical groove between the nose and upper lip), and a thin upper lip.

The provider then takes a family history from the parents that reveals the mother did not realize she was pregnant until she was almost in her sixth month and that she had drunk alcohol and smoked cigarettes during that time. After learning of the pregnancy, she continued to drink, but not heavily, and smoke on occasion. She states the baby has always had some unusual features.

How would you code this case study?

Coding the Primary Diagnosis

“There are four types of fetal alcohol syndrome disorders: partial fetal alcohol syndrome (PFAS), which, due to the lack of obvious characteristics, can often go undiagnosed; alcohol-related neurodevelopmental disorder (ARND), which is characterized by behavioral or cognitive deficits; alcohol-related birth defects (ARBD), which is characterized by the facial characteristics but not growth or development issues; and fetal alcohol syndrome (FAS) says Chelle Johnson, CPMA, CPC, CPCO, CPPM, CEMC, AAPC Fellow, billing/credentialing/auditing/coding coordinator at County of Stanislaus Health Services Agency in Modesto, California.

“Common elements to look for in the documentation for FAS are all three facial features — the small eyes, thin upper lip, and smooth philtrum, which must be present for the FAS diagnosis — growth issues, brain malformation and neurological deficits,” Johnson adds.

Consequently, as many of these symptoms are present in the patient, your pediatrician would most likely diagnose the patient with FAS. But, as the patient is past the 28th day of life, you will not be able to use P04.3 (Newborn affected by maternal use of alcohol). Instead, given the patient’s age and the associated conditions, you would report Q86.0 (Fetal alcohol syndrome (dysmorphic)), according to Johnson.

Coding caution: In a case where you are called upon to use P04.3, you should note that Q86.0 is an Excludes1 code, and you will not be able to report both codes.

Coding the Facial Anomalies

Two codes could come into play for your documentation here. For the palpebral fissure, you could choose H02.89 (Other specified disorder of eyelid), and R68.89 (Other general symptoms and signs) will cover the other dysmorphic features.

Coding the Physical Growth

A number of other signs and symptoms codes will come into play when you code the child’s height and weight, including R62.52 (Short stature (child)) and R63.6 (Underweight). You’ll need to pay attention to the note accompanying R63.6, too, as it tells you to use an additional code to identify the patient’s body mass index (BMI) if known. This will lead you to the Z68 (Body mass index) codes, where you will need to choose a pediatric BMI from the Z68.5- codes. In this case study, you would use Z68.52 (Body mass index (BMI) pediatric, 5th percentile to less than 85th percentile for age) assuming your pediatrician has recorded that the patient’s BMI is above the fifth percentile.

More signs and symptoms codes could also come into play here, including R62.51 (Failure to thrive (child)). Because of the child’s age, like the primary diagnosis, the R62.51 code would be preferred over the newborn code P92.6 (Failure to thrive in newborn), which is an Excludes1 code for R62.51 anyway.

Coding the Child’s Cognitive and Physiological Development

Here, the coding can be challenging, as so many variables can come into play. In this particular case study, codes you could use might include:

  • Balance: Codes from the R26.- family, such as R26.81 (Unsteadiness on feet).
  • Poor muscle tone: M62.9 (Disorder of muscle, unspecified).
  • Fine motor skill problems: F82 (Specific develop­mental disorder of motor function).
  • Cognitive delays: R62.50 (Lack of expected normal physiological development in childhood, unspecified) or R62.0 (Delayed milestone in childhood).
  • Feeding difficulties: R63.3 (Feeding difficulties).
  • Sleep disorders: Codes from the G47.- family, such as G47.00 (Sleep disorder, unspecified).

(For a more comprehensive list of codes associated with FAS, go to the American Academy of Pediatrics Fetal Alcohol Syndrome Coding Factsheet at

And Don’t Forget …

A case such as this will represent a large time commitment on the part of your pediatrician. You’ll want to code a high-level evaluation and management (E/M) service from 99201-99215 (Office or other outpatient visit for the evaluation and management of a new/established patient …). Significantly, “this type of visit will include a lot of counseling, so you’ll need to choose a code based on time and make sure your pediatrician documents that time accurately,” says Donelle Holle, RN, president of Peds Coding Inc., and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana.

In addition, “if the parents were to bring a chart from the hospital, and the physician reviewed it prior to seeing the baby, you can also bill the non-face-to-face prolonged E/M code 99358 (Prolonged evaluation and management service before and/or after direct patient care; first hour), and possibly even +99359 (… each additional 30 minutes (List separately in addition to code for prolonged service) if the work involved merits it. Time, of course, has to be documented as well as what was reviewed, and the prolonged E/M can be billed by itself or billed on the same date if the review was performed on the same date as the visit,” Holle reminds coders.