tci ED Coding & Reimbursement Alert - 2013 Issue 5

Peds ED Documentation: Handy Checklist Helps You Ace Peds E/M Encounters

To be sure you’re capturing all the pediatric-specific information you should for ED visits, use this list provided by Candace E. Shaeffer RN, MBA, RHIA, and Chief Compliance Officer of Optum’sLYNX Medical Systems business unit, to guide your documentation. ·         Vaccinations—Give specifics. Details are preferable to up-to-date or “UTD” ·         Include notation of alleged/suspected physical/sexual assault or molestation and domestic abuse/neglect of children ·         Query tobacco use—don’t forget passive...

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