ICD-10 and Procedure Codes Related to ACEs

So when we use a screening tool for ACEs, we can use a procedure code to capture it. That code is:

96160 Administration of patient-focused health risk assessment instrument (e.g., health hazard appraisal) with scoring and documentation, per standardized instrument

• • • Here is the screening tool for adults ACE Questionnaire for Adults.pdf
    • Here is a guide for family practitioners from MacKay & Taylor (2020)  ACEs Booklet Family Practitioners.pdf
    • Here are the screening tools for pediatric patients from ACES Aware (n.d.)
      • Child: PEARLS-Tool-Child-Parent-Caregiver.pdf
      • Teen: PEARLS-Teen-Parent-Caregiver.pdf
      • Teen, Self Reported: PEARLS-Tool-Teen-Self-Report.pdf

If you are interested in the ICD 10 coding options that may be used for ACEs in adults (and sometimes children), I did a little research and found some - there are probably more but here are a few according to ICD10Data.com (n.d.-a):

• Z00 - Z99 Factors influencing health status and contact with health services
  • Z62 Problems related to upbringing
  • Z62.81 Personal history of abuse in childhood
  • Z62. 812 Personal history of neglect in childhood
  • Z62.898 Other specified problems related to upbringing
  • Z62.9 Negative life events in childhood  
  • Z91.49 Other personal history of psychological trauma, not elsewhere classified
  • Z87.828 Personal history of other (healed) physical injury and trauma
  • Z91 Personal risk factors, not elsewhere classified

And the Z59 Child Codes section has individual diagnoses codes for SDOH! From Codify (n.d.) here they are:

• • Z59 Problems related to housing and economic circumstances
  • Z59.0 Homelessness
  • Z59.1 Inadequate housing
  • Z59.2 Discord with neighbors, lodgers and landlord
  • Z59.3 Problems related to living in residential institution
  • Z59.4 Lack of adequate food
  • Z59.5 Extreme poverty
  • Z59.6 Low income
  • Z59.7 Insufficient social insurance and welfare support
  • Z59.8 Other problems related to housing and economic circumstances
  • Z59.9 Problem related to housing and economic circumstances, unspecified

Terrific, right??

So, we can use the Z59 codes to capture issues related to pediatrics, and the codes in the previous section are probably better used for adults, if I am understanding it correctly. Finally, here are a few more interesting codes:

• • R68.13  Apparent life threatening event in infant (ALTE)
  • R68.19  Other nonspecific symptoms peculiar to infancy
  • Z62. 21 Child in welfare custody

The Diagnosis Related Groups (DRG) dataset 951 is for "Other factors influencing health status" (ICD10Data.com, n.d.-b, title). "DRGs are used for determining reimbursement and as an indicator for other types of reporting such as budgeting, physician profiling, clinical outcomes, case mix calculation and clinical research" (The University of Texas Medical Branch at Galveston, n.d., para. 13).

Additional note to remember:

Z codes in general are used as secondary codes, unless it is for an encounter (Z00.00, Z00.121, Z00.129, etc).

And here is a linked resource that is terrific: Tips for ACEs Related Coding  It summarizes coding practices, like I attempted to above. It was put together by the New Jersey Chapter of the American Academy of Pediatrics (NJAAP) (2019). 

References

ACES Aware. (2023, March 16). Screening tools. Learn About Screening. https://www.acesaware.org/learn-about-screening/screening-tools/ 

Codify. (n.d.). ICD-10-CM code for problems related to housing and economic circumstances Z59. https://www.aapc.com/codes/icd-10-codes/Z59 

ICD10Data.com. (n.d.-a). 2023 ICD-10-cm diagnosis code z62: Problems related to upbringing. https://www.icd10data.com/ICD10CM/Codes/Z00-Z99/Z55-Z65/Z62-/Z62 

ICD10Data.com. (n.d.-b). DRG 951. 2023 DRG List Page. https://www.icd10data.com/ICD10CM/DRG/951 

MacKay, L., & Taylor, M. (2020, December 16). A toolkit for practitioners. ACEs Booklet FPs v8-Electronic.pdf. https://divisionsbc.ca/sites/default/files/Divisions/Kootenay%20Boundary/ACEs%20Booklet%20v5_Electronic.pdf 

New Jersey Chapter of the American Academy of Pediatrics (NJAAP). (2019, May 20). TIPS for aces-related coding . Tips for ACEs Related Coding_noMark.pdf. https://njaap.org/wp-content/uploads/2021/10/Tips-for-Coding.pdf 

The University of Texas Medical Branch at Galveston. (n.d.). Description of coding and DRG assignment. Revenue Cycle Operations. https://www.utmb.edu/rco/Employees/DCDA 

ACEs - Adverse Childhood Experiences

I was assigned some courses on ACEs and there was a great TED talk on the subject. Here are links to what I was to use in preparation for answering the questions below. I highly recommend the training, it was great!

• TED Talk - Nadine Burke Harris
  
• ACEs Training Modules
  

The questions were simple, and were meant to be a basic reflection of learning posted in a group discussion. 

Discuss your thoughts about what you have learned about ACE's. Did you know anything about them before this week's assignments?

I did know about ACEs before completing this week's assignment(s), and I have always felt very fortunate to have had a childhood that resulted in the score I have for ACEs. I first learned about ACEs in 2016 when my sister in law was completing her third master's degree - yep third. She is a Vice Principal now, but was initially a special education teacher, then a grade school principal in a school district filled with kids from socioeconomically challenged homes. The average ACE scores for the kids in her elementary school was seven. Seven!! 

She was discussing it with me in 2016, and I had not heard of ACEs before, that I recall. What she shared with me, and learning about ACEs, inspired me to learn as much as I could about SDOH. I eventually went on to write my master's thesis with a focus on teaching nursing students about SDOH, and for my capstone I developed a curriculum for nursing students to learn about SDOH and I addressed ACEs and the correlation between SDOH and ACE scores throughout the curriculum.

If so, did you learn anything new?

I actually did learn something new this go-around. I did not realize that the ACEs are strongly considered preventable - I mean - I guess maybe cynically speaking, I did not feel empowered to succeed in preventing most ACEs. According to Centers for Disease Control and Prevention [CDC] (2023), "...we must understand and address the factors that put people at risk for or protect them from violence. Creating and sustaining safe, stable, nurturing relationships and environments for all children and families can prevent ACEs and help all children reach their full potential" (para. 13). 

Who knew? "...can prevent ACEs..." I certainly didn't know. 

How will what you learned affect how your provide care for your pediatric patients? 

I suppose this new awareness entreats me to gather as much information as I can about school, community, government, and private resources that I can share with pediatric patients and their parents/caregivers, when I recognize signs of ACEs in my patients.

According to the Cleveland Clinic (2023), signs of an adverse childhood event can include:

• • Fear of other people
  • Difficulty sleeping or frequent nightmares
  • Bedwetting
  • Changes to their mood
  • Difficulty showing affection towards friends or family
  • Avoiding situations or events that relate to a traumatic experience
  • Difficulty learning in school

But what are the warning signs before an ACE occurs?

There aren't really warning signs, as much as there are common risk factors. The Cleveland Clinic (2023, para. 9) indicates the common risk factors for ACEs include:

• • children assigned female at birth
  • minority racial or ethnic groups 
  • children with socioeconomic challenges
  • children of caregivers who experience stress
  • children who have family members/friends with substance use disorder or other mental health condition

And although "ACEs are common across all populations," (CDC, 2021, para. 13), I will be more likely to help prevent ACEs for my patients if I:

• • maintain awareness of the most common risk factors
  • identify the risk factors during my assessment of the patient
  • intervene to extirpate the risks I can identify 

What I learned from this assignment, will strongly impact my practice moving forward, and ultimately benefit the patients that are in my care.  

References

Centers for Disease Control and Prevention (CDC). (2023, June 29). Fast facts: Preventing adverse childhood experiences. Violence Prevention. https://www.cdc.gov/violenceprevention/aces/fastfact.htmlLinks to an external site. 

Centers for Disease Control and Prevention. (2021, April 6). About the CDC-Kaiser ace study. Violence Prevention. https://www.cdc.gov/violenceprevention/aces/about.htmlLinks to an external site. 

Cleveland Clinic. (2023, April 4). Adverse childhood experiences (aces) & childhood trauma. Cleveland Clinic. https://my.clevelandclinic.org/health/symptoms/24875-adverse-childhood-experiences-ace