From the Research
The ICD-10 code for establishing care for a pediatric patient is Z76.2, which represents "encounter for health supervision and care of other healthy infant and child". This code is used when a new pediatric patient is seen for an initial visit to establish care with a provider, without any specific complaint or illness. For well-child visits or preventive care, you might instead use Z00.129 (encounter for routine child health examination without abnormal findings) or Z00.121 (with abnormal findings) if issues are discovered during the exam. If the child has a specific medical condition that is being addressed during the establishing care visit, that condition should be coded as the primary diagnosis, with Z76.2 as a secondary code.
These codes help healthcare providers properly document and bill for initial pediatric visits while ensuring appropriate medical record documentation for continuity of care. According to the most recent study 1, the use of ICD-10 codes for pediatric patients has been increasing, and it is essential to use the correct codes to ensure accurate documentation and billing. The study also highlights the importance of using ICD-10 codes to track social determinants of health in pediatric patients.
Some key points to consider when using ICD-10 codes for establishing care in pediatric patients include:
- Using the correct code for the specific type of visit, such as Z76.2 for an initial visit to establish care
- Using additional codes to document any specific medical conditions or concerns
- Ensuring accurate and consistent coding to facilitate continuity of care and billing
- Staying up-to-date with the latest coding guidelines and updates, such as those discussed in the study 2, which updated the Diagnosis Grouping System for pediatric emergency department visits.
Overall, using the correct ICD-10 codes for establishing care in pediatric patients is crucial for ensuring accurate documentation, billing, and continuity of care.