ED Coding and Reimbursement Alert

CPT® Contains Age Specific Codes For Common ED Services. Check Out These Documentation Dos and Don’ts For Pediatric Critical Care and Burn Patients

Just as there are clinical differences in how you would treat a pediatric patient from an adult with the same presentation in the ED,there are things you’ll need to ensure that your physician notes when assigning codes for those services.

Even if your facility does not have a dedicated pediatric ED, chances are you see a significant number of younger patients; pediatric age parameters vary, but those patients under age 18 are commonly considered to be pediatric.

Overview: 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, saysCandace E. Shaeffer RN, MBA, RHIA, and Chief Compliance Officer of Optum’s LYNX Medical Systems business unit.

Apply These Pediatric SpecificCodesAs 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; there will be 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; under,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 TBSAfor 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, 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 complexity, explains Shaeffer.

CMS says: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.”

Get 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, andfeeding 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 inpatientservices, not for the ED site of service use. 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 services delivered by a physician, face to face, during an inter-facility transport of a critically ill or 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 must accompany 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

A 9 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. Your would report this service with 99291, critical care first hour of care in the ED, an outpatient setting

A 10day-old baby is admitted to the inpatientneonatalcritical 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.

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—coders won’t always 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 the 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 interventionsfor 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 often 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.

Dx code specificity:ED physicians need to be sure to get details in to support proper ICD-9 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(493.02Extrinsic asthma, with (acute) exacerbation); asthma unspecified (493.90Asthma, unspecified, unspecified)is a source of frequent denials.

Know These Audit Hotspots

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. EMTALA protocols aside, says Shaeffer, some situations you should watch for include:

·         A condition that has been ongoing for more than a 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 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 “Do’s” 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 MD 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 ofthe 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.