Pediatric Documentation for ICD-10

Being a specialty that already has a low financial margin, pediatric practices must ensure increased specificity in the documentation of their findings to avoid financial setback just after ICD-10 implementation. If pediatricians continue to follow the same documentation practice they have been following, the diagnoses will map to unspecified codes that may not be reimbursable. Most of the diagnoses require much more specific details in ICD-10-CM. Pediatricians should specify the episode of care and laterality, give more details of the location of an injury or condition and clearly indicate the presence of the symptom, manifestation or complications in their documentation. Let’s take a look at the additional documentation required for pediatric diagnoses.


You should specify the type of asthma (mild intermittent, mild persistent, moderate persistent, severe persistent, or other) as well as whether asthma is uncomplicated with exacerbation, or with status asthmaticus. The cause of the asthma (for example, exposure to environmental tobacco smoke, history of tobacco use, or occupational exposure to environmental tobacco smoke) should also be specified.

Otitis Media

It is required to specify the type of otitis media (serous, sanguinous, suppurative, allergic, mucoid), its severity (acute, chronic, subacute, or recurrent) and laterality (left, right, or bilateral). You should also clearly specify the presence of any associated perforated tympanic membrane, as well as any environmental factors (for example, tobacco use, tobacco dependence, or history of tobacco use).

Well-child Exam

For ICD-9, it is required to focus on the child’s age while documenting for a well-child exam. Since ICD-10 distinguishes between “with abnormal findings” and “without abnormal findings,” make sure that you document the specific abnormal finding, if present. It is also very important to clearly document the treatment and evaluation of abnormal findings discovered.


In ICD-9-CM, it is required to specify the purpose for the immunization along with the documentation for immunization. In ICD-10-CM, the documentation of immunization is sufficient.


ICD-10-CM requires more specific documentation of diabetes. You must specify the type of diabetes (Type 1, Type 2, drug- or chemical-induced, due to an underlying condition (specify the condition), or gestational), any body system affected and/or complications. It is also required to indicate the use of insulin.


This is a new concept in ICD-10-CM and denotes the cases in which a patient takes less dose of a medication than what is prescribed. While documenting for underdosing, specify whether it is intentional or unintentional. If it is intentional, specify whether it is due to financial hardship or some other reason. If it is not intentional, specify whether it is due to an age-related debility or some other reason.


When documenting injuries, you must document the exact site (with laterality) of the injury and the episode of care (initial, subsequent or sequelae). Specify the external cause (how the injury was sustained), place of occurrence (the place where the injury occurred), activity (what the patient was doing at the time of injury) and the external cause status (leisure activity).


If the patient is diagnosed with bronchitis, you must document acuity (acute, chronic, or subacute) and the causal organism (for example, respiratory syncytial virus or metapneumoviris). However, do not change your clinical decision-making process just to achieve greater specificity.

Feeding Problems in Newborns

In this case, you must document the specific type of feeding problem such as slow feeding, overfeeding, or regurgitation and rumination.

Overall, ICD-10 requires pediatricians to be more mindful of specificity at the time of documentation. Complete and detailed documentation helps you to organize observations and examination, justify your treatment plan, support diagnoses, and track patients’ progress and outcomes. This will also help you determine the severity of illness, length of hospital stay and risk of morbidity/mortality data.

You can undertake an audit of your documentation and make sure everything is documented appropriately for ICD-10. If it is too hectic for you to produce much specific documentation amidst providing patient care and other core activities, consider obtaining support from experienced and skillful medical transcriptionists knowledgeable in the latest developments in healthcare field. Professional transcription companies provide three levels of quality control to ensure the accuracy of documentation. The advantage of hiring a transcription service is that you can continue dictating your patient notes, while transcriptionists convert them into text and enter the details into your EMR system. This is a good practice because it will help you meet Meaningful Use requirements efficiently and also enjoy streamlined documentation.