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Pediatric PE Coding: Look Out for These Documentation Misses

Posted on 03. Apr, 2009 by in Toolkit

Here’s why oral thrush could be a major issue.

You can make your pediatric E/M coding easier if the physician knows what needs to be in the medical record and what does not. This is especially true for the physical exam portion of the E/M, which is often under-documented on claims.

Hear Dr. Tuck’s Top 10 at the Pediatric Specialty Coding Conference in Orlando, July 9-11.

There are, however, a few tips you can use to make documenting the PE portion of the pediatric E/M easier. Check out this advice from Jeffrey Linzer Sr., MD, FAAP, FACEP.


Remember, “a red ear doth not an ear infection make,” Linzer said. When documenting an ear exam during a pediatric E/M, be sure to indicate the presence or absence of fluid behind the tympanic membrane. If there is fluid, include a description, Linzer...

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