ED Coding and Reimbursement Alert

To be sure you’re capturing all the pediatric-specific information you should for ED visits, use this list provided by Candace E. Shaeffer RN, MBA, RHIA, and Chief Compliance Officer of Optum’sLYNX Medical Systems business unit, to guide your documentation.

·         Vaccinations—Give specifics. Details are preferable to up-to-date or “UTD”

·         Include notation of alleged/suspected physical/sexual assault or molestation and domestic abuse/neglect of children

·         Query tobacco use—don’t forget passive exposure, alcohol and drug history—and what about steroid use in those young would-be athletes?

·         Query lead exposure, if applicable

·         Clearly document the medical necessity for moderate sedationassociated with lac repairs, CT, and other procedures that don’t usually require Moderate Conscious Sedation in an adult patient.

·         Pediatric patients tend to have fewer interventions, tests; however, their history and physical exam are often more extensive—explain rationale connecting the presenting problem to the work up and plan of care.