The document discusses the coding and documentation challenges encountered in pediatric medical care, including evaluation and management, well-child visits, and diagnosis coding issues. It highlights the specific documentation requirements for pediatric patients in accordance with CMS guidelines, such as variations in recorded information for infants, children, and adolescents. The presentation also addresses common office procedures and the use of chronic condition status in lieu of traditional history of present illness elements.

1. Pediatric coding and documentation challenges
Presenter
Kim Garner-Huey
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Understand the Various Coding and Documentation Challenges you
Face for Pediatric Medical Care

2. Evaluation and Management
Office
Hospital
Counseling
Well-child Care
Common Office Procedures
Vaccinations and Other Injections
Diagnosis Coding Issues
Underutilized Codes

3. Evaluation and Management
Services
Same Documentation Guidelines as for adults
Limitations?
• Review of Systems on small child?
• Social History
– School performance
– Extracurricular activities
– Marital status of parents/Living arrangements

4. CMS Documentation Guidelines
“For certain groups of patients, the recorded
information may vary slightly from that
described here. Specifically, the medical
records of infants, children, adolescents and
pregnant women may have additional or
modified information recorded in each
history and examination area.”

5. Evaluation and Management
History of Present Illness
In lieu of HPI elements, can list the status of
three chronic conditions –
CMS clarified that this can also be applied to
the 1995 Guidelines
How often will you use this in Pediatrics?

6. To see the complete presentation check the
below link:
http://www.audioeducator.com/pediatrics/challenges-pediatric-coding-
documentation-09-10-2014.html