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February 2015

Pediatric Documentation — It's Not Child's Play
By Jennifer Lesnek, RN, CCDS, and Katherine "Kitty" Kremer, BA, RHIT
For The Record
Vol. 27 No. 2 P. 10

Health care documentation is an extremely complex endeavor, especially when it comes to pediatric care. This early documentation of health status serves as a baseline throughout the continuum of care for years to come.

Experience has taught us that pediatric patients are not just small adults, but rather a clinical population with their own unique set of issues. For instance, the top three reasons for pediatric hospital admissions are respiratory complaints, infectious conditions, and chronic/congenital disease issues. In contrast, the top reasons for adult admissions are congestive heart failure, dysrhythmia, chronic obstructive pulmonary disease, and osteoarthritis. Because documentation guidelines generally refer to how to chronicle adult care, pediatric providers face several challenges in their quest to maintain accurate patient records.

Additionally, pediatricians sometimes complicate documentation by not indicating a clear diagnosis. Many pediatricians are reluctant to "label" or "saddle" the patient with a diagnosis that may follow him or her through life or indicate that the patient is sicker than he or she actually is. In this case, documentation specialists can play a key role in working with the physician to develop an acceptable and accurate diagnosis that will provide optimal reimbursement.

Pediatric Clinical Experience Wanted
All of this points to the need for pediatric providers to utilize highly skilled clinical documentation specialists (CDSs) and coders who understand their specialty and can accurately capture the services provided to maximize every reimbursement opportunity. Coders who do not have pediatric clinical experience are unfamiliar with the different clinical indicators that present in this population and may miss opportunities to claim reimbursement for services provided or erroneously document the diagnosis or service, leading to a denial.

While pediatric patients may be admitted with the same or similar conditions as adults, their clinical picture is often different because of immature body systems and different physiological responses. When reviewing the medical records of young patients, CDSs must lean on their pediatric clinical experience to look for the appropriate indicators which can vary, even within the population, depending on the child's age. Vital signs and the physical exam can provide important information to guide knowledgeable CDSs to confirm the proper documentation or make an appropriate physician query.

Disease Specifics
Several conditions in the pediatric environment present unique documentation challenges. For example, disease processes such as bronchopulmonary dysplasia (BPD) and cystic fibrosis, primarily seen in the pediatric setting, require specific documentation to be accurately captured in coding. The term "chronic lung disease" (CLD) is commonly used synonymously with BPD, but there is a difference that must be reflected in the coding.

BPD, a chronic pulmonary disorder caused by unresolved or abnormally repaired lungs, typically is seen in very low birth weight infants who have experienced oxygen toxicity from mechanical ventilation. On the other hand, CLD is a more general term to describe infants who will require ongoing treatment beyond the neonatal period (at or after 36 weeks). CLD is a less specific code, while BPD more accurately reflects the disease process. When CLD has been diagnosed but records indicate the possibility of BPD, a query must be launched for clarification.

Children experiencing an acute exacerbation of cystic fibrosis require inpatient treatment for bronchiectasis and complicated pneumonia. Cystic fibrosis patients also can become colonized with pseudomonas, staphylococcus aureus, and hemophilus influenza at an early age. When a cystic fibrosis diagnosis code is indicated, there are several possible query opportunities that can lead to the more specific documentation required for optimal reimbursement. Coders can query the provider to specify the type of exacerbation/manifestation (eg, gastrointestinal, pulmonary) as well as to define the nature of the pulmonary manifestation.

Chronic/congenital conditions in this population, with diagnoses such as tracheal stenosis and hydrocephalus, can impact coding and audits when lacking the necessary specificity. Whether a condition is congenital or acquired, its circumstances must be clearly indicated. A diagnosis not specified as congenital or acquired may automatically default to an either/or entry.

Emergency Department Revenue
Pediatric patients often experience acute comorbid and major comorbid conditions such as acute respiratory failure, acidosis, and hyponatremia. However, when these conditions occur in otherwise healthy children, they often are treated and resolved relatively quickly, and often such conditions improve significantly or are completely resolved prior to transfer from the emergency department to the general medical floor. It is crucial that emergency department physicians accurately document such conditions to avoid lost reimbursement opportunities.

October 1 Challenges
With the October 1 compliance date fast approaching, astute providers recognize that ICD-10 preparations should be moving full steam ahead. Pediatric providers must build ICD-10 action plans tailored specifically to their practice needs so physicians, administrators, coders, and billers are ready when the new codes take effect.

Common pediatric conditions such as fractures and asthma require additional specificity in ICD-10. Fracture documentation must include information indicating laterality, type (open or closed), encounter, and body part. An asthma diagnosis requires indications of severity (mild, moderate, or severe) and frequency (intermittent or persistent).

ICD-10 is not the only hurdle facing health care organizations come October 1. On the same date, Medicaid will transition to the all patient refined diagnosis-related group (APR-DRG) system, making it imperative for facilities to accurately capture all abnormal/clinical conditions to reflect severity of illness and risk of mortality. The APR-DRG system was developed to more accurately reflect clinical complexity rather than relying on one single complication or comorbidity. While change is always challenging, in the long run the new system will expedite reimbursement as well as assist in the collection of useful data.

Accuracy Is the Objective
Complete and precise clinical documentation that reflects the scope of services provided facilitates accurate reimbursement, a critical factor in the ongoing success of every health care provider, including pediatric physicians. Pediatricians must be educated about the importance of providing detailed, specific documentation of diagnoses and procedures, especially in light of the new ICD-10 requirements. Coders should be encouraged to query when clarification is deemed necessary, helping to ensure proper reimbursement and prevent audit takebacks.

For optimal performance, coders and CDSs should have pediatric clinical experience to be better able to spot the indicators unique to that patient population. Also, every pediatric facility must have a comprehensive clinical documentation improvement program in effect or in the works, either utilizing its own resources or those of an outside specialist. Best practice policies and procedures can be established and rolling audits can be used to track progress and identify educational opportunities and trends. This information then can be used to strengthen physician and CDS relationships to help foster high-quality and accurate documentation.

— Jennifer Lesnek, RN, CCDS, is a clinical documentation specialist at Anthelio Healthcare Solutions.

— Katherine "Kitty" Kremer, BA, RHIT, is director of coding education at Anthelio Healthcare Solutions, an AHIMA-approved ICD-10-CM/PCS trainer, and an AHIMA ICD-10-CM/PCS ambassador.