Mastering Pediatric Codes

by Gerri Walk, RHIA, CCS-P, Health Record Services

Introduction

As we all know, children and adult healthcare issues are very different. This is why there are pediatric specialty hospitals; as well as, pediatric departments within acute care or outpatient facilities. The same goes for coding. General coding and pediatric coding are not the same.

In order for pediatric coding to be done correctly coders must have a very strong understanding of the various congenital conditions, syndromes and chronic illnesses that occur in children. In addition, there are unique coding rules governing diagnosis and age of onset. Despite a growing need for focused training, there are many coders working outside of pediatric specialty facilities who lack formal education or specificity in pediatric coding.

In addition to a solid knowledgebase of some specific healthcare problems that occur in children, there needs to be a good understanding of the reimbursement impact, effective physician query methods and the credible coding resources that coders can turn to as valuable educational resources

Background

There are five common areas within pediatric coding that cause problems and confusion for coders both within and outside of pediatric specialty hospitals.

#1 - Cardiac Surgery

There are several aspects about pediatric cardiac surgery that are important to understand in order to correctly code those cases. These include anatomy and physiology, disease pathology, and timing of condition and/or procedure. Cardiac surgery is typically performed on children when there is a birth defect, however, the total defect may not be repaired in a single operation. In addition, cardiac catheterizations in children often have a very different underlying purpose and expected outcome than those performed on adults.

#2 - Acquired versus Congenital Conditions

Understanding which conditions are congenital versus acquired and the "age of onset" of the acquired have a significant impact on coding for many conditions. These will be explored during the session.

#3 - Syndromes

If the syndrome is identified specifically in ICD-9 then only the syndrome should be coded. If the syndrome is NOT identified in ICD-9 then code 759.89 plus each specific defect.

#4 - Chronic Illnesses

The specific issues and treatments for pediatric chronic illnesses must be clearly identified. The 5 most common chronic illnesses in children will be reviewed along with an explanation of correct coding for each.

• Cystic Fibrosis
• Reactive Airway Disease
• Otitis Media
• Spina Bifida
• Cerebral Palsy

#5 - V-Codes

It is important to set facility-specific guidelines for the use of V codes in pediatric patients. While there is no right or wrong answers here, it is important that consistency across the coding staff be maintained. Also, coders should be cautious to overuse general categories such as drug allergies and family history in pediatric coding.

Methods:

Beyond the five most common coding issues in pediatrics, coders must be aware that sequencing of codes becomes more important and has a stronger impact on reimbursement assignment. This is because in pediatrics, the circumstances of some admissions can be debatable and if the patient underwent multiple procedures, coders have to determine which one is principal. Also, As example a DRG 392 - Gastroenteritis with Dehydration vs a DRG 641 - Dehydration with Gastroenteritis is a difference of $115.

Speaker will give coders advice and guidelines on code sequencing to ensure correct MS-DRG assignment.

Strategies:

One of the most commonly used strategies for coders in non-pediatric specialty hospitals is the use of physician query alongside pediatric coding education.

When questions need to be asked of the physician, it is critical for the coders to formulate the question in a manner to extract the right information to properly code. Examples of effective and ineffective queries for pediatric coding will be shared.

Finally, it is important that pediatric coders have easy access to the coding resources they need. A list of resources will be provided along with description and benefits of each.

Conclusion:

By becoming more knowledgeable of the unique pediatric healthcare conditions, syndromes and procedures and by learning to better sequence diagnoses and ask more targeted questions when querying physicians, coders should be able to more effectively handle pediatric coding. The result will be more accurate coding, better quality data and right reimbursements.