Pediatric PE Coding: Look Out for These Documentation Misses

Posted on 03. Apr, 2009 by Editor 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.

EARS

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 recommended.

Example: “Fluid behind tympanic membrane is red-yellow, purulent.”

MOUTH

When documenting an ENT PE for a child, note any tonsilar fullness or uvular deviation. Also, remember that exudates are not always an indication of strep, according to Linzer.

Watch for thrush: Linzer reminded coders to be on the lookout for signs of oral thrush, especially in pediatric patients more than 12 months old, as this could indicate a weakened immune system, which can be a sign of leukemia or HIV.

LUNGS

On the lung PE portion, be sure to document effort and work of breathing. You should also note the quality of any cough, Linzer offered.

Example: You might describe a cough as a “smoker’s hack,” a “dry wheezing cough,” or a “seal bark.”

The medical record should also indicate which sounds came from the patient’s upper airway, and which ones...

Tags: abdomen, E/M, ear infection, ENT, evaluation and management, lungs, oral thrush, PE, pediatric, physical examination