Eli's Rehab Report

Question: I struggle with documenting onset dates with our pediatric cases. For example, for a child diagnosed with cerebral palsy (343.9), the onset date would be the child’s date of birth — but what if the treatment diagnosis is an abnormal gait (781.2)? Obviously the child wasn’t walking at birth. Should the onset date then correlate with the treatment diagnosis? If so, how should I determine the onset date? Also, how should I document prior functional status for a developing child with a condition like cerebral palsy?

Answer: In pediatrics, you generally have a lot of leeway with onset dates that you don’t have with the adolescent, adult or geriatric population. So you could technically correlate the onset date to either the medical or the treatment diagnosis. Depending on what age at which you’re seeing the child, you should lean toward an onset date corresponding to the treatment diagnosis for the abnormality of whatever you are seeing the patient for. The onset date for the treatment diagnosis could be the date the physician saw the child and diagnosed that abnormality.

As far as documenting prior functional status when you have no prior functional status to compare to, compare the child’s status, instead, to a healthy child. For example, if you’re administering therapy to a 3-year-old with an abnormal gait, ask yourself, how should a 3-year-old be ambulating compared to how this 3-year-old is ambulating?

You have to be able to describe what’s abnormal in your documentation.