Experience in Medical Coding Crucial for Pediatric Documentation

Experience in Medical Coding Crucial for Pediatric Documentation

Outsource Strategies International 8596 E. 101st Street, Suite H Tulsa, OK 74133

www.outsourcestrategies.com | 1-800-670-2809

The need for reliable medical coding services is always felt by hospitals and practices in various healthcare fields, but one area where this is crucial is pediatric coding.

Medical Coding Services to Deal with Pediatric Coding

As if healthcare documentation wasn’t complex enough, documenting pediatric care takes the complexity level even higher. One of the major reasons for this is that documentation guidelines usually deal with chronicling adult care. This makes maintaining accurate records tougher for child care.

Pediatric conditions are different from adult issues as is evident from the main reasons for pediatric hospital admissions - infectious diseases, congenital disease and respiratory issues. On the other hand, the major reasons for adult hospital admissions

are

conditions

such

as

dysrhythmia,

congestive

heart

failure,

osteoarthritis and chronic obstructive pulmonary disease. The two categories therefore involve different sets of issues.

Experience Counts in Pediatric Documentation

Pediatricians also do not indicate a clear diagnosis since they do not want the patient to be labeled with any kind of illness that would sound more serious than it actually is. Incorrect records based on unclear diagnosis would affect the child all through life.

In such situations the role of experienced coders and documentation specialists is important in order to collaborate with pediatricians to develop a diagnosis that is accurate and acceptable to ensure patient welfare as well as optimal reimbursement.

Experience in pediatric clinical documentation is therefore of utmost importance.

Pediatricians should have experienced medical coders and clinical documentation

www.outsourcestrategies.com

800-670-2809

specialists handling this task. They would be able to figure out their specialty to capture accurately the provided services for maximizing reimbursement opportunities.

Coders without pediatric experience would miss out on reimbursement opportunities.

They could also wrongly document services or diagnoses which would cause denied claims. Knowledgeable clinical documentation specialists can identify the vital signs to ensure the right documentation. Experience and intuition are everything when it comes to pediatric documentation, which is why reliable medical coding services can prove invaluable.

ICD-10 Changes

The arrival of ICD-10 codes has made pediatric coding trickier. ICD-10 has brought about changes in definition and terminology as well as greater specificity. Here’s an example of increased specificity:



Breastfeeding difficulties for newborn babies, classified by ICD-10 as infants up to 28 days old, are documented according to the minute problems faced.

Three of the examples are the following:





Neonatal breastfeeding difficulty – P92.5



Slow feeding – P92.2



Regurgitation and rumination – P92.1

Injury is another example of the greater specificity involved in ICD-10.

Documentation should be very detailed and include the episode, the specific site of injury, the etiology describing how the injury was caused, the place where

the

episode

occurred,

whether

the

injury

was

accidental

or

unintentional, and whether the occurrence was civilian, military, or of any other status.

So, for example, a strain injury on the left knee caused by

www.outsourcestrategies.com

800-670-2809

incorrect jumping from a trampoline in a private playground must involve the following codes:



S86.812A for injury caused by other muscle or tendon strain at the

lower leg, left leg, initial encounter 

W09.8xxA for falling on or falling from other equipment in a

playground, initial encounter 

Y92.838 to indicate other recreation area as the place of occurrence of

the injury 

Y93.44 to denote activities consisting of rhythmic movement, which in

this case is trampoline jumping

This level of specificity and detail needs to be maintained in chronicling all kinds of pediatric conditions, which calls for experience and a deep understanding of the condition.

With reliable medical coding services by trained and experienced coders, the chance of errors in pediatric documentation would be minimal, no matter how complicated the coding is.

www.outsourcestrategies.com

800-670-2809