Guest Post: Pediatric reviews: Know the rules before you play the game

by Robert S. Gold, MD

Even experienced and consistently accurate acute care hospital coders may not be familiar with pediatric diseases. Age is not a factor for some conditions (e.g., appendicitis). Others are age-specific or have age-specific diagnosis, healing, and treatment implications. Coders must consider this when assigning codes and querying physicians.

Consider a Colles’ fracture. It occurs in both children and adults, but the healing process is different because of the growth plates in the pediatric population. Aspiration pneumonia can present in both groups, but the cause may differ anatomically and microbiologically. Bronchospasm in adults likely has a completely different cause than in children. Diabetes may have similar long-term outcomes, but type 1diabetes is more difficult to manage psychosocially than type 2 in the pediatric population.

Numerous examples illustrate the differences between pediatric and adult diseases. Bacterial causes of pneumonia differ based on age group. Cerebral hemorrhage may have the same fatal outcome in children and adults, but rarely the same cause. Physicians must approach causes of respiratory distress in children quite differently. Heart failure is completely different in the two groups. Even the types of cancers that occur in children are different.

For example, diabetes, anemia, and heart failure have very significant implications in pediatric coding.

Diabetes

A physician documents that a 10-year-old has unspecified diabetes. Should you query whether it’s type 1 or type 2? You need clues before deciding. If a patient has cystic fibrosis, chances are that patient has diabetes secondary to cystic fibrosis. If this is true, it would map to code series 249. Look for other documented diseases (e.g., leprechaunism, mongolism, pituitary tumors, adrenal tumors). All of these can cause secondary diabetes.

Also determine whether the child is very obese. Does the child have Prader-Willi syndrome or another genetic abnormality? Is obesity due to overeating and familial problems? If so, it may be acquired type 2 diabetes.

Anemia

Don’t assume that anemia documented without other specificity means acute blood loss anemia. Coders must consider many pieces of evidence before arriving at this conclusion when reviewing a pediatric chart. Certainly, a child with a fall and a head laceration can have significant blood loss. A traumatic rupture of the spleen can also cause anemia due to acute blood loss. However, children may experience spontaneous splenic rupture more frequently than adults. Children don’t have diverticulosis in the traditional way; however, they do have angiodysplasias of the intestinal tract that can break loose. Children can also have a Meckel’s diverticulum that, when lined with gastric mucosa, can cause significant hemorrhage from the small intestine next to the Meckel’s.

Children can have many nutritional and genetic causes of anemia. They can also have some very abnormal-looking red cells. Coders should familiarize themselves with pediatric causes of anemia and with what the red cells might look like when one of them is present. Coders shouldn’t frame a question regarding causes of anemia citing a plethora of potential causes. Don’t ask the general question, “What’s the cause of the child’s anemia?” Physicians won’t likely provide the answer you seek unless the cause is completely genetic (e.g., sickle-cell anemia, thalassemia minor). Pediatric cases generally are not this simplistic.

Heart failure

Many coding guidelines pertaining to heart failure are based on an article published by the American College of Cardiology and the American Hospital Association titled “Guidelines for Management and Treatment of Chronic Heart Failure in the Adult.”

The title indicates that heart failure presentation and treatment differs in children and adults. Pediatric heart disease is underrepresented in ICD-9. The classification system includes some pediatric congenital abnormalities, but it doesn’t include many manifestations included in the adult heart disease section.

The heart is supposed to develop from two parallel tubes that supply the branchial arches in the developing embryo. These parallel tubes join in the midline and evolve into two separate circulations with separations between chambers and valves to direct flow. If the separation doesn’t coalesce properly, the patient can develop septal defects. If the endocardial cushions don’t develop properly into valves, the patient can have misdirected flow. If the outflow tract doesn’t divide properly and evenly, the patient can have problems with misdirected flow and pressure. These are congenital heart defects. These defects can result in shunting of blood from the oxygenated side to the deoxygenated side (without cyanosis after birth) or from the deoxygenated side to the oxygenated side (with cyanosis after birth). A patient with such heart defects who develops overcirculation to the right side (left to right shunting) will develop pulmonary edema. This can be termed “heart failure,” but it’s not similar in any way to adult heart failure. Therefore, don’t request additional specificity because physicians aren’t able to provide it—it doesn’t exist.

Sometimes the heart almost develops properly. A pediatric patient may have a single valve problem or a persistent shunt (e.g., an atrial septal defect, patent ductus arteriosus). When a patient has a shunt, the direction of flow makes a difference in how the child presents and adapts to the shunt. A septal defect with flow from the normally higher-pressured left side to the normally lower-pressured right side (left to right shunt) may be asymptomatic. A septal defect in the face of primary pulmonary artery hypertension can lead to significant flow from the right (deoxygenated) side to the left (oxygenated) side. It can also lead to symptoms (e.g., hypoxemia or cause an individual to be cyanotic when at rest).

In the case of a single valvular stenosis or regurgitation, a child can develop ventricular dysfunction (left or right ventricle, depending on which valve is involved) over time. The child may eventually develop chronic left ventricular dilation with low ejection fraction (systolic dysfunction) or hypertrophy with normal ejection fraction (diastolic dysfunction). The patient may also go into acute heart failure. At this point, coders have an opportunity to seek additional specificity.

Skilled acute care coders and those working in clinical documentation improvement for adult conditions must think twice before coding and querying about pediatric conditions.

Editor’s Note: This article was published in the October issue of Briefings on Coding Compliance Strategies. Dr. Gold, at the time of this article's release, was CEO of DCBA, Inc., a consulting firm in Atlanta that provides physician-to-physician clinical documentation improvement programs.