Pediatric Coding Alert

Coding for possible and obvious trauma cases can be easy if you know what to look for There's a simple rule of thumb when reporting child abuse exams: They generally require mid- to high-level E/M visits and use ICD-9 codes that reflect an observation, injury, sign, symptom or abuse. Often, the first question is: What is child abuse? It's "any recent act or failure to act on the part of the parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation," says Jeffrey Linzer Sr., MD, FAAP, MICP, EMS coordinator for the emergency pediatric group at Children's Healthcare of Atlanta at Egleston during the "Child Abuse Reporting Do's and Don'ts" teleconference produced by The Coding Institute. Abuse can include "an act or failure to act which presents an imminent risk of serious harm," he adds. Sometimes the abuse is obvious, while at others, a parent may suspect abuse but none is found. Handling these difficult situations can prove emotionally challenging without having to worry about reporting the services properly. Start With the Office Visit Generally, the amount of documentation and medical decision-making during office visits for suspected child abuse will rise to level four or five (for example, CPT 99214 , Office or other outpatient visit for the evaluation and management of an established patient ...), Linzer says. The pediatrician often performs a detailed or comprehensive examination and takes an extensive history. And he has to consider both the child's physical and mental well-being during any medical decision-making. For example, a father brings his 11-month-old daughter into the office because she is limping. He explains that "the baby was just starting to pull herself up to stand, but now she won't crawl." After performing a detailed physical exam, ordering x-rays and reviewing a detailed patient history with the father, the pediatrician finds a femur fracture (821.xx, Fracture of other and unspecified parts of femur ...). In this case, you would probably report 99214 based on the level of care provided. With no history of previous trauma, the physician becomes suspicious that this may be child abuse. Consequently, additional ICD-9 codes other than 821.xx will depend on the doctor's findings and expertise with the child's injuries and abuse. If the pediatrician definitely thinks that abuse occurred after a thorough investigation, you should report 995.54 (Child physical abuse) and add 821.xx to indicate the specific injury. Keep in mind: Whether you confirm or only suspect the abuse, state law requires you to make a report to the designated authorities. Even in the case of suspected abuse, you are not making an accusation when filing the report. Although you may know that an injury is caused by [...]