Experience in Medical Coding Crucial for Pediatric Documentation
Experience in Medical
Coding Crucial for Pediatric
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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
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
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.
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
incorrect jumping from a trampoline in a private playground must involve the
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
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
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.