Pediatric Coding Alert

This speed sheet keeps your abdominal pain claims ICD-9 compliant.

See if youre complying with ICD-9 guidelines when reporting abdominal pain. What diagnosis would you use on the following example?

CC: 5-year-old girl here today for stomach pain.

HPI: Right-sided sharp abdominal pain for 1 day,worse with movement, no vomiting or diarrhea. Temp to 101 today. Last BM this morning, normal consistency.

ROS: Without cough, rashes, joint pain, or urinary symptoms

Exam:

Constitutional: Uncomfortable, but in no acute distress.

Skin: Clear; turgor: good.

HENT: Pharynx benign; chest clear to auscultation.

Heart: Reg rhythm, w/o murmur.

Abdomen : Decreased bowel sounds in RLQ, tenderness to deep palpitation in RLQ with rebound.

Rectal exam: No localized tenderness or palbable masses.

Step 1: Check for Specificity

If you didnt spot RLQ in the exam, you might think 789.00 (Abdominal pain, unspecified site) would be the appropriate ICD-9 code to list for the documentation. You would instead report the specific quadrant diagnosis that thepediatrician indicates in the exam: 789.03 for RLQ pain.

Why not default to 789.00 if the pediatrician documents a specific area? Because it would be against the Coding Guidelines, notes Jeffrey F. Linzer Sr., MD, MICP, FAAP, FACEP, associate medical director of compliance and business affairs for the division of pediatric emergency medicine Department of Pediatrics at Childrens Healthcare of Atlanta at Egleston.

A coder is supposed to code to the highest level of specificity based on the physicians documentation, Linzer explains. So if the doctor writes RLQ pain, it would be inappropriate for a coder to use the unspecified site code because a site was specified.

Step 2: Recognize Quadrant Indicators

Although specific abdominal pain diagnoses can lurk anywhere in the chart, coders can pick out pertinent details by becoming familiar with key terms. Q abbreviations such as RLQ for right lower quadrant and LUQ for left upper quadrant, as well as phrases like diffuse, indicate abdominal pain locations that map to specific fifth digits as follows:

Step 3: Save Ticket Space Without Risk

Dont fret if you cant squeeze all the above entries on your superbill. Just include a space for the pediatrician to indicate the exact location. For instance, a charge ticket entry could read: Abdominal Pain 789.0__ Location:

________.

If the physician wrote LLQ and RLQ pain, then the coder would use 789.09 because this is the default code for multiple sites, Linzer says.

For easy physician lookup using an EMR, in the database load the system with the diagnosis codes, Brown suggests.

Example: Alphabetically list Abdominal Pain(rather than Pain, Abdominal), then list each area with its coordinating code, such as:

Abdominal Pain  ,unspecified 789.00

                        ,periumbilic 789.05

                        ,epigastric 789.06.