Pediatric Coding Alert

NKDA and C/C/E wont trip you up thanks to quick quiz.

Even an auditor experienced with the CMS standard worksheet might stumble over some medical abbreviations and terms, missing eligible items. Heres a quick primer to improve your documentation reading.

Give Physician Flex Credit for NKDA

Question 1: You see NKDA in a charts review of systems (ROS). Can NKDA count as:

a. ROS -- allergic/immunologic

b. Past history

c. HPI

d. a or b

Answer 1: D. You cannot double dip! Although you cant give credit for No Known Drug Allergies (NKDA) under both ROS and past family social history, the abbreviation can fall under either history element.

Reviewer B may state that the documented NKDA constitutes an element of ROS or conversely an element of Past history, according to Stephanie Jones, CPC, CEMC,vice president of product management for the American Academy of Professional Coders in Salt Lake City.

Become Familiar With Key Abbreviations

Question 2: Youve got murmur documentation to indicate a cardiovascular (CV) exam review, but you dont know where to put c/c/e. Is this notation, plus CV, enough body areas/systems for expanded problem-focused exam?

Answer 2: Yes, c/c/e stands for cyanosis (blue color of the feet or hands), clubbing, edema (swelling). Physicians may use the medical abbreviation no c/c/e, for instance, to indicate adequate blood oxygenation in physical examination of the extremities. Thus, you have two body areas/systems examined (cardiovascular, extremity), which equates to a limited number or expanded problem-focused exam.

If the physician goes further into the body area or system than usual, this could indicate an extended exam. The 1995 E/M Documentation Guidelines distinguish between the two levels only in that they both require at least two body areas and/or systems and that one is a limited exam and the other is extended, Jones notes.

If you had not already counted a CV review, you could have counted edema toward the cardiovascular system, notes F Tessa Bartels, CPC, CEMC,reimbursement manager for pediatric surgery/craniofacial remodeling at Medical College of Wisconsin in Milwaukee. Alternatively, clubbing and cyanosis could go to musculoskeletal. Heres support:

The 1997 guidelines show the following bullet under Musculoskeletal:

" Inspection and/or palpation of digits and nails (e.g.,clubbing, cyanosis, inflammatory conditions, petechiae,ischemia, infection, nodes)

The 1997 guidelines show the following bullet under

n

Cardiovascular:

" Examination of extremities of edema and/or varicosities

Try this: Our practice usually uses 1995 guidelines,but the definitions under 1997 guidelines sometimes help me identify what system Im looking at, Bartels says.