ED Coding and Reimbursement Alert

Plan of care should describe any refused treatments, too. Coding for pediatric patients who require ED E/M services can get tricky fast if you don't know the coding nuances that separate children from adult ED patients. And if you forget to describe even a single component of the overall service, it could lead to downcoding, which will cost the practice reimbursement. Last month, in "Detail Marks Successful Pediatric E/M Histories," we explored best practices for recording the history and review of systems portions of a pediatric ED E/M. This time, we-ve got expert advice on documenting physical exam (PE) and plan of care, as well as some tips on selecting the service level for your younger ED patients. Aim to Answer -Sick- Question With 6 Words The medical record for a pediatric E/M claim should include "short, clear descriptions of the child's general physical status," explained Jeffrey Linzer Sr., MD, FAAP, FACEP, 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. In a nutshell: "Is this a sick child or not a sick child? The physician should answer this in six words or less," Linzer said during his recent audioconference, "ED Services for the Crayola Set: How to Keep the Red Off Your Pediatric Claims" (http://www.audioeducator.com). Check out these succinct notes that provide detail on the physical exam portion of the pediatric E/M: - "Child is smiling, happy, playful." - "Child fears physician, consolable by mother." - "Child somnolent, difficult to arouse." - "Child fears physician, inconsolable." You should be sure the exam part of the medical record has documentation that ties the organ systems included in the examination to both the presenting problem and information gathered in the history. Example: "While on a recent camping trip, we had to take my 4-year-old son to the area's local ED when he fell from the top bunk of our camping trailer and had a laceration of his scalp," offers Debra Pierce, MD, MBA, CPC, founder and managing member of Pierce MD Consulting LLC in Rockbridge, Ohio. "The [encounter] documentation should obviously indicate his scalp wound, as well as reference to other aspects of his skin integrity, constitutional, and neurologic status," she explains. (For more information on documenting physical exams for pediatric E/M patients, see "Clip and Save: Pay Special Attention to These Areas of Peds PE.") Document -I Didn't Do It- When documenting plan of care (POC) for the medical record, what the physician doesn't do might be as important as what he does. This is especially true when the child's caregiver objects to a [...]