Same ED Rules Apply to Pediatrics, but Outcomes May Be Different

Be sure pediatric ED documentation and coding reflect the demands of your specialty.

By Jim Strafford, CEDC, MCS-P
Emergency department (ED) coding is place-of-service driven. Coding the five ED levels (99281-99285) and critical care is governed by the American Medical Association’s (AMA) CPT® guidelines, as well as the Centers for Medicare & Medicaid Services’ (CMS) 1995 Documentation Guidelines for Evaluation and Management Services (the 1997 guidelines are seldom used). These guidelines ensure ED coding is consistent across all EDs—with one major exception: pediatric EDs (EDs caring for patients primarily from birth to 21-years-old).
The basics of charting pediatric EDs are the same as in other EDs: Complete and accurate documentation of all elements of history/physical and medical decision-making (MDM) are necessary for complete and accurate coding. But in terms of chief complaints (CC)/nature of presenting problem (NOPP), acuity metrics, type of care rendered, and documentation challenges (3-year-olds aren’t very good historians), pediatric EDs vary significantly from “regular” EDs. Because pediatric ED visits and treatments are sometimes unique and not always well represented by documentation guidelines, particularly regarding MDM, pediatric ED visits are often “undervalued.”

Know CC/NOPP Differences

CCs/NOPPs are critical documentation and coding elements because the ED course and MDM are driven by the presenting signs and symptoms of an “always-new-to-the-ED-provider” patient. Pediatric EDs see very few Medicare patients, and common complaints generally differ from those of middle-aged adults and the elderly. Proper coding requires an understanding of the types of cases pediatric EDs see on a regular basis, as well as the challenges ED providers face in treating young patients.
Cardiovascular (CV)
For example, pediatric EDs see very few myocardial infarctions, unstable anginas, cerebro-vascular accidents, etc. As a result, pediatric EDs have lower inpatient admission rates than “all patient” EDs and lower acuities overall. This does not mean that pediatric EDs never see high-level or critical care, CV-related patients. But cases are infrequent and typically involve children with congenital defects, chronic problems related to the CV system that have exacerbated, or another condition we’ll discuss later.
Respiratory
Respiratory complaints are common in all types of EDs, but it’s rare for pediatric patients to present with the same underlying causes as the elderly (often, congestive heart failure or chronic obstructive pulmonary disorder (COPD)-related). More often, children presenting in the ED with respiratory complaints suffer from asthma or respiratory infections.
Acute exacerbation of asthma is a common reason for children to come to an ED, and often justifies critical care. This is especially true if multiple interventions and constant attendance is required to stabilize the child.
For example, a 9-year-old male reports to the ED with difficulty breathing, wheezing, and a pulse oximetry reading of 94. Multiple nebulizer treatments, oxygen, intravenous meds, and monitoring to prevent pulse oximetry measure from decreasing below 92 are provided. Treatments do not alleviate the symptoms completely and the child is admitted.
There is the risk of respiratory system failure in such a case, which justifies the need for immediate and ongoing intervention. Although this should qualify for critical care, ED charts indicate pediatric ED physicians often do not document these cases as such.
Documentation of 30 minutes or more of critical care is required for the attending physician to code critical care (the 30 minutes of critical care must be provided by the attending physician, not the resident). Pediatric ED coders and auditors should be providing feedback to pediatric ED physicians on the rules of critical care coding and charting where there is a clinical indication of critical care, but time is not documented.
Injuries
All EDs treat their share of injuries. And the types of injuries are often the same regardless of age. A broken bone is a broken bone at any age, for example. But how did the bone break? Children are typically injured on playground equipment, while playing sports, riding on bicycles, all-terrain vehicles, scooters, or roller skates, and in motor vehicle accidents as passengers and pedestrians. The E codes you use to describe injury causes might vary slightly from adults but should be coded as specifically as adult injuries.
The treatment of injuries is similar from child to adult. Often, radiologic studies are ordered and immobilization is completed by the provider, nurse, tech, etc. For example, the treatment of a 10-year-old and of a 30-year-old suffering an ankle sprain while playing basketball would be similar—typically pain relief, X-ray, and immobilization. There is no reason for the child’s sprain to be coded at a lower level than an adult sprain. It’s usually a level III ED visit (99283 Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of moderate complexity), depending on documentation.
The risk related to a childhood injury can be greater than an adult in terms of bone growth, etc. To ensure services are coded at the appropriate level, providers should document all risks related to the injury, diagnostics review (if they separately reviewed an X-ray), management of immobilization or completed application, and consults with specialists such as orthopedists.
When the attending physician provides restorative care service in the ED, as is often the case with fingers, toes, clavicle, and ribs, he or she must document the fracture care rendered: diagnostics, immobilization, medication, etc., as well as referral information. If the child is immediately referred to an orthopedist, fracture care coding is not appropriate.
Injury is an area where pediatric ED services may be undervalued for a number of reasons. Treatment protocols for kids are often different than for adults and may not be fairly represented in MDM guidelines. Another reason may be that pediatric EDs have “flown under the radar” in our industry. Most pediatric EDs are at academic medical centers and simply haven’t been scrutinized by the industry, making it difficult to identify pediatric ED benchmarks for comparison purposes. EDs or other practices that treat all ages have public access to Medicare numbers (and other sources) to use for comparison purposes. Because pediatric EDs see few Medicare patients, Medicare benchmarks are statistically insignificant.
There are significant risks and challenges in treating children, toddlers, and infants. Services must be well documented for you to code the proper E/M level.
Fever
Many children report to pediatric EDs with fever and associated symptoms. Sometimes labs are drawn. The patient is often treated with acetaminophen (not a prescription drug, but a medication of choice for fever and other conditions). A strict interpretation of the Table of Risk in CPT®’s E/M guidelines, requiring “prescription drug management,” might result in coding the service at a lower level. Many such cases involving labs and sometimes diagnostics do not meet strict compliance with the Marshfield Clinic audit worksheet guidelines (the MDM guidelines most often used); but the children nonetheless are very sick and require significant treatment. You should weigh medical necessity and the risk unique to each case, especially for toddlers and babies, when determining the ED level to be coded.
Overall ED Acuities
Coding managers or auditors can look for different acuity metrics between pediatric and general ED visits. All-ages EDs (often with 20-30 percent Medicare patients in the payer mix) should anticipate acuities more weighted to the higher levels than pediatric EDs. The following table shows a comparison of acuity mixes typical for all-ages EDs verses pediatric ED visits:
The bell-shaped curve expected for ED E/M often is not seen with pediatric EDs. As the Office of Inspector General (OIG) and CMS have noted, the all-ages ED bell curve has shifted significantly to the 99284-99285 range in recent years. Pediatric EDs often have a “camel” curve, with 99282 and 99284 being the humps. This is due to the mix of pediatric ED patients presenting primary care problems for minor problems, such as rashes, etc.

Conditions Exclusive to Childhood

Many children are taken to pediatric EDs for exacerbation of chronic or congenital conditions that are unique to their age group. At a major teaching pediatric hospital in the Northeast, there are a significant number of ED admits for children with cystic fibrosis. Pretty much any respiratory symptom with cystic fibrosis can be potentially life threatening.
Often seen only in pediatric EDs is a common childhood malady known as “nursemaid’s elbow” or pulled elbow. The medical term is “radial head subluxation,” or in layman’s terms, a partially dislocated elbow joint. This encounter is coded with CPT® 24640 Closed treatment of radial head subluxation in child, nursemaid elbow, with manipulation and ICD-9-CM 832.2 Dislocation of elbow; nursemaid’s elbow.
Sadly, many children visit EDs as a result of abuse. Again, the Marshfield Clinic audit tool might not adequately reflect the complex and sensitive nature of these visits. ED providers should clearly document the entire visit, including involvement of other healthcare providers, such as caseworkers, diagnostics, etc.

Get It in Writing

The history/physical/MDM guidelines apply to all ED visits, whether adult or child. Pediatric EDs often differ from adult EDs in terms of clinical and payer mix, presenting problems, and course of treatment, however. To ensure ED E/M levels aren’t undervalued, providers must clearly document all pediatric conditions, both chronic and emergency, as well as the risks of treatment.

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