ED Coding and Reimbursement Alert

Watch for age specific codes and rules for common ED services like moderate sedation and burns. 

Even if your facility does not have a dedicated pediatric ED, chances are you see a significant number of younger patients who qualify as pediatric cases. Read on for a refresher course on how to report services for your youngest patients.

Overview: Pediatric age parameters vary; pediatric patients are often under five years of age, but patients under age 18 are also commonly considered to be pediatric. The majority of pediatric ED visits are for respiratory problems and minor injuries, with most pediatric encounters covered by private pay, insured by Medicaid or commercial payers, says Candace E. Shaeffer RN, MBA, RHIA, and Compliance Officer for Optum360’s LYNX product technology and coding services.

Keep in mind: A pediatric patient differs from an adult with the same presentation in the ED in terms of clinical treatment, so your coding for pediatric treatment will need to reflect that difference. 

Apply These Pediatric Specific Codes As Appropriate

In addition to the ED E/M codes, you should also be aware of the pediatric specific codes available in CPT®. The performance of services like attending at delivery, birthing room resuscitation, or new born care (99464, 99465, 99460-99463) would be infrequent in a larger ED with sufficient obstetrics specialist and resident coverage; these are per day codes and, as such, there is a greater likelihood of utilization in community or rural hospitals, says Shaeffer.

Similarly, there are age specific codes that describe pediatric procedures like moderate sedation, venipuncture and inserting central venous catheters or PICC lines. Be sure you chose the age appropriate code when a pediatric range is offered, such as 36555 (Insertion of non-tunneled centrally inserted central venous catheter; younger than 5 years of age), warns Shaeffer.

Rule of Nines is Age Specific When Dealing With Pediatric Burn Patients

Because the human anatomy changes as we age, make note for the percentages of body surface area assigned to various body parts for “rule of nines” assignment of burn codes. For example, an infant’s head makes up a much larger percentage of its total body surface area (TBSA) than the head of an adult. For this reason, the assigned percentage of TBSA for the head decreases as a patient ages from 18 percent in a newborn to 9 percent for a teenager. Legs are the opposite in that they account for 14 percent of a baby’s TBSA, but increase to 18 percent for an adult patient, says Shaeffer.

Record Specifics on General Appearance, Not Just “Normal”

Pediatric clinical info is often provided by another person, since the patients themselves are too young or incapable of doing so. In those situations you must document the source of information in the record. The limited communication ability with very young patients can affect the encounter’s complexity, explains Shaeffer.

Read the fine print: While the CMS and CPT® documentation guidelines apply to both adult and pediatric patients, CMS states in the documentation guidelines, “For certain groups of patients, the recorded information may vary slightly from that described here. Specifically, the medial record of infants, children, adolescents and pregnant women may have additional or modified information recorded in the history and exam…these patient group variations on history and exam are appropriate.” 

Document these specifics: General appearance in pediatrics is more important than with adults in documenting the severity of the presenting problem, Shaeffer stresses. For newborns/infants, include in the history as appropriate: pregnancy history, delivery type, and complications, newborn health, and feeding issues. Social history will include family structure, second hand smoke exposure, and family history should address any congenital or hereditary disorders in the family, Shaeffer advises.

What’s “normal”? “Normal” varies between pediatric age groups and individual patients, so the best practice is to be more specific in your documentation of these patients during the physical exam, says Shaeffer. Normal weight or development for a preadolescent may be very different from that of a teenager. Be sure to note what is normal or abnormal for the child’s age and situation. Pediatric patient documentation should include a weight — either an accurate weight or a standard estimate method for critical patients for use in calculating medicinal dosages, such as the Broselow Tape, she adds.

Factor in These Critical Care Details

Pediatric critical care may not be as apparent to ED coders, so the chart documentation needs to be explicit. Critical care rules are consistent from pediatric to adult patients, but presenting problems vary, such as pediatric fever, dehydration or croup.

Critical care provided in an outpatient setting is generally reported with 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and 99292 (…each additional 30 minutes [List separately in addition to code for primary service]), but don’t forget that other pediatric codes are available in CPT® that capture high intensive services. However they may not easily apply to the ED setting.

Caveat: Neonatal critical care codes 99468—99469, and pediatric critical care codes 99471-99476, are for inpatient services, not for the ED site of service use.  Also, keep in mind that these are “per day codes” and are not usually reported by the ED physician.  

Furthermore, if your coding takes you beyond just the ED, CPT® states that when critical care is provided on the same day by the same physician in both the inpatient and outpatient settings, then, per CPT® instructions, ONLY neonatal/pediatric critical care codes are reported. Additionally, time-based critical care services (99291, 99292) are not reportable by the same individual or different individuals within the same group when neonatal or pediatric critical care services (99468-99476) are reported.

Codes 99466 (Critical care face-to-face service, during an interfacility transport of a critically ill or critically injured pediatric patient, 24 months or younger, first 30-74 minutes of hands-on care during transport) and 99467 (…each additional 30 minutes) are available if the emergency physician accompanies the pediatric patient during transport. 

Tip: Think of this as rolling or flying critical care outside the ED setting, says Shaeffer.  

Check Out These Examples

An 8 year-old presents to the ED in hypovolemic shock secondary to diarrhea and dehydration. The emergency physician provides constant attention, rehydrating and stabilizing the patient, totaling 72 minutes. You would report this service with 99291, critical care first hour of care in the ED, an outpatient setting

A 15 day-old baby is admitted to the inpatient neonatal critical care unit with respiratory distress syndrome. The attending physician orders intubation, and continuous respiratory and blood pressure monitoring with repeat exams throughout the day. In this scenario, you would report the neonatal critical care code 99468 for the whole day’s care in an inpatient setting.

Just Close Your Eyes And This Won’t Hurt A Bit

Pediatric presentations, such as laceration repairs or reducing fractures, frequently involve moderate sedation.  Achieving the appropriate level of sedation can be tricky in younger patients, especially those under five years of age. If the child actually requires deep sedation, you should choose the appropriate code from the anesthesia section. 

But if moderate sedation is used, don’t forget that CPT® has pediatric codes for moderate sedation both in support of your own procedure or when you are providing the sedation for another physician doing the procedure. 

As a reminder, the chart documentation must exceed the midpoint of the intra-service time listed in the CPT® code descriptor in order to report the timed service; in this case 16 minutes.

99143 (Moderate sedation services [other than those services described by codes 00100-01999] provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient’s level of consciousness and physiological status; younger than 5 years of age, first 30 minutes intra-service time)

99148 (Moderate sedation services [other than those services described by codes 00100-01999], provided by a physician or other qualified health care professional other than the health care professional performing the diagnostic or therapeutic service that the sedation supports; younger than 5 years of age, first 30 minutes intra-service time)

Look for Details on Severity/Criticality and Diagnoses

Subtle changes in an infant’s or child’s behavior and appearance can have significant meaning in terms of severity of an illness or injury. ED physicians may document these changes, but many coders won’t recognize these nuances. 

For pediatric critical care, ED physicians should note the meaning of signs and symptoms and critical care indicators for both coders and auditors to easily follow their MDM thought process, Shaeffer stresses. 

Examples where additional MDM documentation might be helpful include nasal flaring or retractions in an infant, or lethargy in an ill neonate.  Clinical evaluation is different for some presenting conditions in pediatric patients such as fever, seizure, abdominal pain, etc. 

An ED physician may order fewer tests and interventions for a pediatric patient, making it difficult for coders to assess MDM when the work-up is relatively less than for an adult. 

Chief compliant focus: Sick kids with severe and/or multiple chronic problems requiring daily management may present to the ED with one chief complaint which is addressed, so be sure to make it clear which factors  the coder should consider for E/M coding for the current visit, says Shaeffer. 

Diagnosis code specificity: ED physicians need to be sure to get details in order to support proper ICD-9 or ICD-10 code assignment.  Example: A patient presents to ED with asthma, history of same, and is treated and released. In this case, the patient’s diagnosis should be ideally documented as an acute exacerbation of asthma (493.02, Extrinsic asthma, with [acute] exacerbation); asthma unspecified (493.90 Asthma, unspecified, unspecified) is a source of frequent denials.

It Is Not Just Medicare That Audits Charts!

Pediatric records are not exempt from audit scrutiny, so keep a close eye on these targeted areas. This is increasingly true for denials due to lack of medical necessity for an ED visit. In these cases, thorough documentation is essential. EMTALA protocols aside, says Shaeffer, some situations you should watch for include:

• A condition that has been ongoing for more than a day — what has changed?  What brought the patient to the ED on this day?

• Cases where the presenting problem is not urgent:

• A condition has resolved, or the presenting problem is a “recent history of” 

• The diagnosis is on a payer non-urgent list, if they are using diagnoses to determine medical necessity and a reason for denial or downcoding of an ED visit

• The diagnosis is  not specified as “acute” or “acute exacerbation”

• When no physical problem is found and the only available primary diagnosis is a V code, such as V71-observation and evaluation for suspected condition not found.

• Cases where the medical necessity for the visit was not documented

• Encounters where “nothing was done” for the patient

• Medicaid coverage in states that are especially concerned with non-emergent use of the ED

• EHR and shortcuts: cut and paste, carry forward, etc.

Documentation Tips To Help You Prevent Audit Challenges 

Excellent documentation can help support the visit code reported when a hospital, payer or other entity audits ED records.  Use the following documentation strategies from Shaeffer to assist in supporting positive audit outcomes:

• Documentation of “medical necessity” will help keep those 99283s from being downcoded to level 2 or 1.

• If the doctor discusses diagnostic options with the family and together they decide not to do a test, documentation of  this thought process can frequently be considered in the record’s MDM. An example is when the physician discusses the pros and cons of performing a lumbar puncture for a pediatric patient with a fever.

• Documentation of connections between a patient’s condition, history, exam, orders, findings, risks and plan of care.

• Documentation often emphasizes how well the pediatric patient looks, no distress etc., if appropriate, mild distress is preferable.

• Documentation of the rationale for orders; they don’t usually stand on their own.

• If the patient’s condition is “acute,” document that term with the diagnosis.

• Proceed with caution when using macros and other short cuts; if used, review and modify for the current encounter.

Best bet: Always focus on doing what is medically best for your patient, but be mindful about documentation that will support the actual service provided to help both you and your pediatric patient’s family with the financial aspects of the visit, says Shaeffer.