ED Coding and Reimbursement Alert

When providing E/M services for children in the ED, Jeffrey Linzer Sr., MD, FAAP, FACEP, always reminds physicians and coders of one thing.

"Children are not small adults," Linzer stressed during his recent Audioeducator.com session, "ED Services for the Crayola Set: How to Keep the Red Off Your Pediatric Claims." They have different bodies and minds than grownups, and the ED physician must treat both as such when providing and coding services.

We-ve got the inside scoop on best practices when coding for E/M services for children; check out this info on documenting history and review of systems (ROS) for optimal payer compliance. Look to future editions of ED Coding Alert for more information on pediatric coding.

When documenting the history portion of a child's E/M, you must be specific about who provided this information -- mother, father, babysitter, the child, etc.

"Since children are frequently not the historians, based on age and verbal skills, it is important to note the source of the history. Obtaining the history from a source other than the child adds to the complexity of the evaluation," explains Michael A. Granovsky, MD, CPC, FACEP, president of Medical Reimbursement Systems Inc. (MRSI), an ED billing company in Woburn, Mass.

So if the babysitter brings the child to the ED, she may not be aware that the child had a certain medical condition or was taking a particular medication. "Noting who the historian is provides you with documentation as to who provided you the information, and to show [that the physician] may have been working somewhat -in the dark,-" explained Linzer, who is associate professor of pediatrics and emergency medicine at Emory University School of Medicine in Atlanta; and associate medical director for compliance, Emergency Pediatric Group, at Children's Healthcare of Atlanta at Egleston and Hughes Spalding Atlanta.

For example, a day care provider rushes a child with shortness of breath to the ED. The notes indicate the child is wheezing. The mother then calls the ED and states that the child does not have a history of asthma and has never wheezed before. Further interviewing of the day care provider raises concern for a foreign body aspiration, which the physician confirms via chest x-ray.

Action: On your pediatric E/M claims, be sure to note the source of the patient's history.

Linzer and Granovsky both agree that when taking history, it is best to get quotes directly from the child whenever possible. The physician should not paraphrase for the child or try and "translate" her words, Linzer warned. But the physician may want to indicate the child's perceived meaning in brackets in the documentation.

This is especially important in potential abuse cases, as the physician needs to be careful not to put words in the child's mouth.

Example: Linzer offered this history note using a child's quote: "Child said -He touched me in my coco- [child pointed at vaginal area]."

If the child is unwilling to talk, make sure to document that in the record. And be sure to note whether the physician referred the untalkative patient to a child abuse and advocacy specialist for an interview.

No matter who is giving the medical information for the child's history, coders must avoid terms that could lead to unclear diagnoses -- and potential legal trouble, Linzer warned.

Such as: "-Lethargic- is a great lawyer's word, but a bad medical term," Linzer says. If the historian reports the patient is "lethargic," it could indicate a number of potential medical conditions, or it could just mean "the child is sitting around watching TV and is not as playful as usual," said Linzer.

Words like "-lethargic,- -sleepy,- -inconsolable,- and -irritable- may all suggest significant underlying pathology," says Granovsky.

For example, a child may be irritable because he's hungry or bored -- but it may also be a sign of meningitis. "Using clearer terminology, such as -fussy and hungry but easily consolable- makes it clear that the child is not particularly ill," said Linzer.

Best bet: Make sure that descriptions in the medical record are clear and unambiguous.

For the record, a child's past medical history would include the following:

- the child's immunization status

- any lack of compliance with past medication/ treatment plans

- a social history, indicating the child's school/daycare and home situations.

Granovsky says that past history for a child could also include any of the following: allergies, surgeries, medical conditions and illnesses, birth history (if patient is an infant), and prior hospitalizations.

And don't skimp on the social history documentation for children, Linzer warned. "Just as in an adult, a social history can include work status; the equivalent for a child would be school or daycare attendance or staying at home," he said.

The child's social history should also include any exposure to tobacco, drugs, or alcohol, at home or anywhere else.

When you are reviewing the encounter form for ROS information, make sure that the physician is not suffering from "check all the boxes" syndrome, said Linzer. If the ED physician is checking every ROS box on his pediatric claims, it could send off alerts with auditors.

"This may be taken for habit instead of detailed documentation" during an audit, he said.

Example: The ED physician checks all of the ROS boxes for a 3-month-old female patient.

Problem: "Young children do not have a psychiatric system to review," Linzer explained. In this example, the physician is providing inaccurate ROS documentation.