ED Coding and Reimbursement Alert

Beware: The word -lethargic- in the medical record could cause trouble When providing E/M services for children in the ED, Jeffrey Linzer Sr., MD, FAAP, FACEP, always reminds physicians and coders of one thing. "Children are not small adults," Linzer stressed during his recent Audioeducator.com session, "ED Services for the Crayola Set: How to Keep the Red Off Your Pediatric Claims." They have different bodies and minds than grownups, and the ED physician must treat both as such when providing and coding services. We-ve got the inside scoop on best practices when coding for E/M services for children; check out this info on documenting history and review of systems (ROS) for optimal payer compliance. Look to future editions of ED Coding Alert for more information on pediatric coding. Note Who Gave the Info on History When documenting the history portion of a child's E/M, you must be specific about who provided this information -- mother, father, babysitter, the child, etc. "Since children are frequently not the historians, based on age and verbal skills, it is important to note the source of the history. Obtaining the history from a source other than the child adds to the complexity of the evaluation," explains Michael A. Granovsky, MD, CPC, FACEP, president of Medical Reimbursement Systems Inc. (MRSI), an ED billing company in Woburn, Mass. So if the babysitter brings the child to the ED, she may not be aware that the child had a certain medical condition or was taking a particular medication. "Noting who the historian is provides you with documentation as to who provided you the information, and to show [that the physician] may have been working somewhat -in the dark,-" explained Linzer, who is associate professor of pediatrics and emergency medicine at Emory University School of Medicine in Atlanta; and associate medical director for compliance, Emergency Pediatric Group, at Children's Healthcare of Atlanta at Egleston and Hughes Spalding Atlanta. For example, a day care provider rushes a child with shortness of breath to the ED. The notes indicate the child is wheezing. The mother then calls the ED and states that the child does not have a history of asthma and has never wheezed before. Further interviewing of the day care provider raises concern for a foreign body aspiration, which the physician confirms via chest x-ray. Action: On your pediatric E/M claims, be sure to note the source of the patient's history. Get Quotes From the Child, If You Can Linzer and Granovsky both agree that when taking history, it is best to get quotes directly from the child whenever possible. The physician should not paraphrase for the child or try and "translate" her words, Linzer warned. But the physician [...]