ED Coding and Reimbursement Alert

Plan of care should describe any refused treatments, too.

Coding for pediatric patients who require ED E/M services can get tricky fast if you don't know the coding nuances that separate children from adult ED patients. And if you forget to describe even a single component of the overall service, it could lead to downcoding, which will cost the practice reimbursement.

Last month, in "Detail Marks Successful Pediatric E/M Histories," we explored best practices for recording the history and review of systems portions of a pediatric ED E/M. This time, we-ve got expert advice on documenting physical exam (PE) and plan of care, as well as some tips on selecting the service level for your younger ED patients.

Aim to Answer -Sick- Question With 6 Words

The medical record for a pediatric E/M claim should include "short, clear descriptions of the child's general physical status," explained Jeffrey Linzer Sr., MD, FAAP, FACEP, 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.

In a nutshell: "Is this a sick child or not a sick child? The physician should answer this in six words or less," Linzer said during his recent audioconference, "ED Services for the Crayola Set: How to Keep the Red Off Your Pediatric Claims" (http://www.audioeducator.com).

Check out these succinct notes that provide detail on the physical exam portion of the pediatric E/M:

- "Child is smiling, happy, playful."

- "Child fears physician, consolable by mother."

- "Child somnolent, difficult to arouse."

- "Child fears physician, inconsolable."

You should be sure the exam part of the medical record has documentation that ties the organ systems included in the examination to both the presenting problem and information gathered in the history.

Example: "While on a recent camping trip, we had to take my 4-year-old son to the area's local ED when he fell from the top bunk of our camping trailer and had a laceration of his scalp," offers Debra Pierce, MD, MBA, CPC, founder and managing member of Pierce MD Consulting LLC in Rockbridge, Ohio.

"The [encounter] documentation should obviously indicate his scalp wound, as well as reference to other aspects of his skin integrity, constitutional, and neurologic status," she explains. (For more information on documenting physical exams for pediatric E/M patients, see "Clip and Save: Pay Special Attention to These Areas of Peds PE.")

Document -I Didn't Do It-

When documenting plan of care (POC) for the medical record, what the physician doesn't do might be as important as what he does. This is especially true when the child's caregiver objects to a course of treatment for the patient, which you will have to carefully record to protect the practice from legal red tape.

Caregivers might refuse recommended care for a variety of reasons: religious beliefs, cost, aversion to certain types of drugs, etc. Whatever the reason, if a caregiver refuses recommended treatment, be sure to note it in the record, Pierce stresses.

"This information may be helpful for continuity of care purposes, as well as possible malpractice issues," says Pierce, who recommends that treatment refusal notes include not only the fact that the care was declined, but also include this information:

- the reasons or circumstances for the refusal

- any ensuing discussions after the caregiver refuses the treatment

- any warnings the physician gives the caregiver on potential adverse effects or complications that may result from inaction.

Example: A 14-year-old girl presents complaining of knee pain after the family dog knocked her down. There is swelling around the patella and the patient experiences pain when she moves the leg. Fearing a tibial fracture, the physician suggest x-rays. Both parents are unemployed and the family recently lost its insurance coverage, so they refuse the diagnostic studies because of the cost. The ED physician reviews the dangers of delaying treatment but stabilizes the knee, provides pain relief, and suggests follow-up with the primary care physician (PCP) to monitor swelling and pain.

When recording POC information, the ED physician should also document that she advised the caregiver to follow up with the child's primary care physician, "for both medical and legal reasons," confirms Kent J. Moore, manager of Health Care Financing and Delivery Systems for the American Academy of Family Physicians in Leawood, Kan.

Example: Documentation for discharge might read: "Asthmatic 8-year-old patient sent home with action plan and inhaled steroid prescription on 10-13-08. Instructed caregiver to follow up with child's PCP by 10-16-08 at the latest, even if patient is improving."

Consider Age-Related Risks When Choosing Code

Linzer stressed that coders cannot automatically assume a high service level for extremely young patients; they must base the E/M level on the medical necessity of the encounter, not the patient's age.

This means that an ED E/M for a neonate is not necessarily a 99285 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: a comprehensive history; a comprehensive examination; and medical decision making of high complexity) service.

Certain risk factors present in children however, can increase the level of service.

Example: A pediatric patient presents to the ED with a 100.4 F fever. If the patient is 5 years old, he is not at great risk of morbidity or mortality. But the same fever in a neonate is a much more serious issue -- one that could increase the physician's level of service.

When selecting E/M service level, Pierce says any of the following factors may also affect the service level:

- source of the medical history (patient, parent, direct relative, babysitter)

- how many reassessments the physician performs for the patient

- acuity of the patient's condition

- patient's response to treatment(s)

- any comorbidities the patient has.