This quarterly column is written by Caral Edelberg, CPC, CPMA, CAC, CCS-P, CHC, President of Edelberg Compliance Associates, Baton Rouge, LA.
Attempting to use adult coding and documentation criteria for pediatric ED patients can be a costly and challenging process. Diagnosing the problems of infants and small children who can’t adequately communicate their problems often requires additional time and expertise but isn’t adequately addressed in current coding rules. And trying to sort out Mommy and Daddy’s litany of observed problems with Junior requires additional investigation and consideration of a number of potential problems. Documentation requirements for infants and children often require more detail for appropriate documentation of both the medical necessity and the level of medical decision making to support the additional time and effort required.
Below are some of the conditions and interventions that, for infants and children, may require a higher level of medical decision making than for the same problem in an adult:
- Discussion with Poison Control, monitoring, observation for ingestion in infant, child
- Charcoal for ingestion of toxic substance
- Pediatric suctioning to clear airway
- Severe pain
- Severe nausea and vomiting
- Pediatric lumbar puncture
- PO challenge
- Observation for response to treatment during ED course
- Bites (human, insect, animal, etc.)
- Sedation for procedures.
As parents become more skeptical about vaccinations, and pediatricians become more careful about use of antibiotics in certain age groups, medical decision making actually increases. This is due in no large part to the number and types of situations and outcomes to consider. Additionally, children with birth defects, terminal conditions, or severe chronic problems who present with either acute exacerbations of their condition or additional problems resulting from treatment of their condition (cancer, diabetes, asthma) may require additional consideration in order to treat effectively. Complicating factors such as autism, ADD/ADHD, etc. will add to the time and intensity required to treat even minor cuts and bruises.
How can medical necessity be documented to establish the higher level of medical decision making often required to treat pediatric problems? Here are a few tips for documenting appropriately:
- Be sure to include a complete history of present illness. Ask when the problem first occurred. What made it worse and necessitated an ED visit today? What is the severity of the problem (pain, shortness of breath, treatment-related nausea and/or vomiting, temperature)? What type of home or long-term treatment has been tried and for how long? Is there anything that makes it better or worse? What other problems is the infant/child experiencing?
- Provide details about each system reviewed that is related to the problem. For example, if it is shortness of breath, provide details about the respiratory, constitutional, cardiovascular, etc., as appropriate with more than just a word or two. And remember, you can’t have a negative review of the system referenced in the history of the present illness as the problem. No negative respiratory for an asthma exacerbation and no negative integumentary for a child with infected insect bites on extremities. For those systems not directly related to the presenting problem and found to be negative, document “All other systems reviewed and negative.”
- Make sure the pertinent elements of past medical, social (living arrangements, school, siblings, etc.), and family history are investigated and documented. In almost all pediatric patients, questions related to a past medical and social history are relevant.
- Be sure to provide the details of the physical exam for each of the organ systems and body areas examined. Be sure systems related to the chief complaint and any symptomatic systems are referenced with details.
- Documentation of medical decision making can make or break the payer’s view of medical necessity, and it begins with the HPI. Risk factors, past problems, attempts at resolution, and the details about why the parents brought the child to the ED now help support medical necessity. In addition, consultation with the family physician or other specialists, review of available records, or the necessity of obtaining additional history from the parents as the ED course progresses is an indication of the ED provider’s concern for problems. With pediatric patients, differential diagnoses and/or provisional diagnoses go a long way toward underscoring the need for diagnostic tests and/or ED treatments. However, emergency physicians may consider these alternatives but decide against them. When this occurs, a discussion of the considerations for not performing these tests and interventions should be clearly recorded. This is critical in defending payment denials or audits. Also, when parents refuse recommended treatment or disposition, this should be recorded with resulting risks. Kids don’t generally get the number and type of diagnostic studies that occur in the adult population, but the risk from their problems can be significant.
- The diagnosis statement should be precise, and any other problems treated in addition to the primary diagnosis should be listed. For ICD-10 purposes, the more detail about site, type of problem, progression, co-morbidities, surgical treatment provided, diagnostic findings, etc. is essential. For injuries/ trauma, document:
- Cause – what caused the injury?
- Location – where was the patient when the injury occurred?
- Activity/Accidental/Assault? – what was the patient doing?
- Active or Follow-up Treatment – was this the initial or a subsequent encounter?
- Type (contusion, laceration, sprain/strain);
- Detailed location of site;
- Presence of foreign body.
Finally, watch how you use your documentation templates and voice dictation. The incidence of inappropriate statements and jumbled dictation is becoming more frequent. Check your chart frequently as you complete it and be sure what appears there is what you intended. Auditors find gender-related dictation errors, meaningless text on ROS or PE, and diagnoses containing conditions not referenced anywhere in the record. When this occurs, it calls into question the validity of other information.
Additionally, the failure to document orders that are performed by nursing staff is becoming a common occurrence and is responsible for millions in lost ED facility revenue. If you are ordering meds, IVs, nursing procedures, etc., be sure they are documented appropriately. Documentation defends the treatment provided and the bill you send to the patient or insurer. Be sure you defend your actions by what you write.