Claims & Billing
Review diagnosis age guidelines to ensure proper claims processing

​As our transition to our next generation platform continues, we want to remind you to review the age ranges that are associated with the diagnosis codes reported on the claim. Certain diagnosis codes have age designations assigned to them based on industry standard guidelines including CMS, ICD-10-CM, and the Centers for Disease Control and Prevention (CDC).

Claims with inappropriately matched age to diagnosis codes reported at either the header or claim line level will be considered billing errors and these claims will be denied.

Examples of age-designated diagnoses:

1.  Body Mass Index (BMI) diagnosis codes

BMI codes are categorized into adult and pediatric ranges. The BMI percentiles in the code descriptions are based on growth charts published by the CDC. 

    • Adult codes are used for persons ages 21 or older
      • Z68.20: Body Mass Index (BMI) 20.0-20.9, adult
      • Z68.21: Body mass index [BMI] 21.0-21.9, adult
    • Pediatric codes are used for persons ages 2 – 20
      • Z68.51: Body mass index [BMI] pediatric, less than 5th percentile for age
      • Z68.52: Body mass index [BMI] pediatric, 5th percentile to less than 85th percentile for age

2.  Other pediatric or child diagnosis codes

For other ICD-10-CM diagnosis codes that reference pediatric or childhood in the code category or the code narrative, follow the pediatric age range defined in the ICD-10-CM coding guidelines and report these codes for patients ages 0 – 17:

    • R62.0: Delayed milestone in childhood
    • R63.31: Pediatric feeding disorder, acute

3.  Newborn general exams: Z00.11x series diagnosis codes

Codes for newborn general exams are broken out by the child's age, as stated in the code description itself.

    • Z00.110: Health examination for newborn under 8 days old
    • ​Z00.111: Health examination for newborn 8 to 28 days old

To ensure proper claims processing, the age ranges of the codes reported need to match the patient's age at the time of care. These rules apply to services reported on both 837I and 837P claim transactions.

Look for future articles related to our transition to the new claim processing platform. Visit our dedicated Platform Transition page to stay informed.

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