ED Coding and Reimbursement Alert

You can make your pediatric ED E/M coding easier if the physician knows what needs to be in the medical record and what does not. This is especially true for the physical exam portion of the E/M, which is often under-documented on claims. There are, however, a few tips you can use to make documenting the PE portion of the pediatric E/M easier. Check out this advice from Jeffrey Linzer Sr., MD, FAAP, FACEP.

Remember, "a red ear doth not an ear infection make," Linzer said. When documenting an ear exam during a pediatric E/M, be sure to indicate the presence or absence of fluid behind the tympanic membrane. If there is fluid, include a description, Linzer recommended.

Example: "Fluid behind tympanic membrane is red-yellow, purulent."

When documenting an ENT PE for a child, note any tonsilar fullness or uvular deviation. Also, remember that exudates are not always an indication of strep, according to Linzer.

Watch for thrush: Linzer reminded coders to be on the lookout for signs of oral thrush, especially in pediatric patients more than 12 months old, as this could indicate a weakened immune system, which can be a sign of leukemia or HIV.

On the lung PE portion, be sure to document effort and work of breathing. You should also note the quality of any cough, Linzer offered.

Example: You might describe a cough as a "smoker's hack," a "dry wheezing cough," or a "seal bark."

The medical record should also indicate which sounds came from the patient's upper airway, and which ones emanated from the lower airway.

Upper abdominal pain accompanied by a cough could indicate diaphragmatic fatigue from bronchospasm, so be sure to note it in the medical record when relevant, said Linzer. The record should also include info about any intermittent colicky pain, or the presence (or absence) of an enlarged liver or spleen.

Recommendation: During the abdominal portion of the PE, Linzer always has children "hop, skip, and jump" -- if they are able. "Children with abdominal tenderness usually cannot do this," he explained. If the physician does employ the hop, skip and jump test, remember to note how the child performed in the medical record.