person holding dirt

Most of us are aware of such eating disorders as anorexia and bulimia. One involves starvation and the other involves binge eating and purging.

However, imagine the need to eat soil, cigarette butts, and paint. A person who has experienced such food cravings may have been diagnosed with pica.

The word pica is Latin for magpie, a bird known for its willingness to eat just about anything, according to Psychology Today.

Pica is a rare eating disorder that may develop at any stage of life, but it tends to occur in young children, adolescents, and pregnant women.

Infants and babies learn about the world by putting nonfood items in their mouths, but they normally outgrow the habit by two to three years of age. When pica develops in adults, there is usually a co-existing intellectual disability or other mental disorder involved.

According to Everyday Health and the National Institutes of Health, as many as 32% of children between the ages of one and six display this behavior. The pica cravings are less common in pregnant women.

Children are attracted to such items as soil, paint, pencils, clay, hair, and insects. Adults, on the other hand, tend towards paper, glue, ice, and soap. Other substances that are ingested include cigarette butts, ashes, feces, and starch.

Etiology

There are many potential causes of pica. However, an iron, zinc, or calcium deficiency may be associated with pica in some cases. In fact, in pregnant women, anemia (low iron) is often the cause of pica, because the body develops unusual cravings in response to low nutrient levels.

Mental health conditions, such as schizophrenia or obsessive-compulsive disorder, may lead to pica as a way for the person to cope with the mental health condition. Some people enjoy the textures or flavors of such nonfood items as clay, and it is an acceptable behavior in some cultures. This form of pica is called geophagia. Dieting and malnourishment can lead to pica. Consuming non-food items helps the person feel full.

Diagnosis

A physician who suspects pica will need to perform an evaluation to assess for possible intestinal blockages, anemia, or toxicity from the consumed substances. The physician will also evaluate for signs of other disorders, such as developmental disabilities or obsessive-compulsive disorder, which may be the cause of the eating disorder.

If there are symptoms present, the physician will perform a complete medical history and physical exam. A test may be done to check for potential infections caused by non-food items that have been contaminated with bacteria or other organisms.

Blood tests and X-rays may be performed as well. The person’s eating habits may also be reviewed, but often a patient is dishonest about eating nonfood items due to either embarrassment or believing there is nothing wrong with it.

In order to come to a diagnosis of pica, the patient must exhibit:

  • severe symptoms for at least a month
  • adverse consequences of pica, such as toxic poisoning
  • non-food eating behavior in situations other than during a religious or cultural ritual
  • no other mental disorder that would fully explain the eating behavior, such as obsessive-compulsive disorder

A diagnosis of pica should not be made in a pregnant woman unless the disorder is unusually severe or causes health concerns.

magpie, bird, pica, dirt, eat dirt, non-food stuff

A magpie is known for its willingness to eat just about anything.

Treatment

Due to the risk of medical complications associated with pica, close monitoring of the eating behavior is necessary.

In complex cases, a mental health team is also important. According to WebMD and the Handbook of Clinical Child Psychology, behavioral strategies are most effective, providing training and positive reinforcement to the pica patient when consuming nutritional foods. Some medications, such as escitalopram or olanzapine, may also be helpful in reducing abnormal eating in those with developmental disorders.

Complications Associated with Pica

Many potential complications of pica exist, which include:

  • Paint chips may contain lead or other toxic substances and can result in poisoning. This, in turn, can lead to learning disabilities and brain damage.
  • Non-food items can lead to nutritional deficiencies. In a pregnant woman, this is potentially harmful to the baby as well.
  • Stones or other substances that cannot be digested can cause constipation or a digestive tract blockage, as well as a blockage in the intestines and bowels.
  • Sharp objects, such as paper clips and metal, can cause a tear in the esophagus or intestinal lining.
  • Dirt can carry parasites or bacteria, and this may result in a serious infection, and some infections go on to cause damage to the liver or kidneys.

Blood Work and Lab Tests

Once a patient is diagnosed with pica, they should have certain blood work and lab tests performed on a regular basis to help in their recovery. Some of the basic tests include, among others, a complete blood count (CBC); Electrolytes: potassium, calcium, sodium, phosphorus, and magnesium; liver and kidney function tests; blood glucose; complete urinalysis; bone density test.

Prognosis

Pica usually only lasts for a few months and will stop on its own in children and pregnant women. However, it may continue for years in people with developmental disabilities and can be more difficult to manage.

Medical Coding

According to the 2018 ICD-10-CM Professional Edition For Hospitals, pica can be found in Chapter 5., Mental, Behavioral and Neurodevelopmental Disorders (F01-F99).

Case 1:

A 12-year-old girl presents today with a long history of consuming non-nutritive items. In the beginning, she was non-selective, but later she began to only consume mud that she would retrieve from a wall in the backyard. She was diagnosed with pica.

F98.3, Pica of infancy and childhood

This code can be located in the Alphabetic Index under Pica, infant or child F98.3. It can then be verified in the Tabular.

Case 2:

A 26-year-old female patient has been complaining of fatigue for 4 months. The patient stated she has a habit of chewing on ice (pagophagia) and has been doing this for about 3 years. She also stated that she chews on ice in place of eating nutritious foods for many of her meals. After a thorough workup, the patient was diagnosed with pica.

F50.89, Pica in adults

This code can be located in the Alphabetic Index under Pica, in adults F50.89. It can then be verified in the Tabular.

Billing

According to the Medicare Coverage Database:

  • There are no NCD guidelines addressing F50.89, but there are 15 LCD determinations for this diagnosis.
  • 89 is listed as a covered diagnosis by CMS for many of the diagnostic labs, such as magnesium, which may be pertinent to this diagnosis.
  • Most labs would need to be ordered based on the signs or symptoms, as opposed to the diagnosis of pica (F50.89).
  • 3 is not a covered diagnosis for lab testing under Medicare regulations; a young child will only qualify for Medicare in very rare circumstances.
  • 89 is a covered diagnosis for the therapy portion.

Many of the tests to diagnose pica and the treatments provided are covered under Part B outpatient services:

  • Individual and group psychotherapy sessions with physicians or other licensed professionals permitted by the state in which you receive services
  • Family counseling if it is the main reason for getting help with treatment
  • Testing to find out if you are getting the services you need and if your current treatment is helping you
  • Psychiatric evaluation
  • Medication management
  • Diagnostic tests
  • Partial hospitalization
  • An annual Wellness visit, which is a good time to talk to your physician or another healthcare provider about changes in your mental health so they can evaluate your changes year to year

Commercial payers – No authorization is required for non-genetic diagnostic labs, and there is no concern regarding coverage as long as the plan provides outpatient benefits. The plan may be subject to deductibles, coinsurance, and/or copays. Many plans also cover mental health therapy or treatment.

Medicaid (other than Managed Medicaid plans) – All non-genetic diagnostic labs are covered. There are mandated plan provisions under these policies for mental health treatment. In most cases, there are no copays, coinsurance, or deductibles.

Coverage is based on the individual’s insurance carrier. Some commercial and managed Medicare and Medicaid plans may require prior authorization for mental health benefits. Check with the individual payers for specific plan guidelines.

This article was first published in BC Advantage/www.billing-coding.com under the title, “Pica – The Need to Eat Dirt and Other Non-Food Stuff” and is reprinted here with permission.