By Brian Murphy
The pediatric population is not just little adults. Not clinically, and not when it comes to CDI and coding.
Think about the extended long lengths of stay in the Newborn Intensive Care Unit (NICU) that can range from >128 days due to extreme prematurity, or occasionally up to 2 years, where the patient has become a ward of the state. Or about the incredibly resource-intensive cases that are final coded with a low-paying DRG (pediatric DRGs are notoriously low-paying, with some exceptions), resulting in financial loss.
Think odd procedures, neonatal sepsis, and other clinical presentations that confound even seasoned professionals used to working only within the Medicare population.
These stark differences, and vulnerabilities, mean you need a specific pediatric CDI focus. But where do you start?
A good place is a return to basics. You need to get comfortable working with an old school resource—specifically the ICD-10-CM Manual, your at-the-elbow bible when working these tricky cases.
Too many CDI specialists have become encoder dependent, says Sandra Love, BSN, RN, CCDS, CCDS-O, CPC, senior manager of CDI for Norwood. Encoders are of course necessary, and every CDI professional should have access to one. But, if you use them exclusively, they can constrict and narrow your thinking.
“If you go to put in a word in the encoder and can’t find the word, what do you look for next? Are you going to give up?” she asks. Too many CDI specialists do, and in the pediatric setting that can mean low-weighted diagnoses for very long lengths of stay, and pediatric service lines in financial jeopardy.
Instead of retreat, the first step should be to reach for your coding bible.
“Before you reach out to someone for help, go to your bible. You need to determine what is included, and excluded, and your terminology. Your bible gives you all your hints—your MCCs, your CCs, your HCCs. If it’s not in the bible, you’re not going to query for it.”
An example is dysgenesis of the corpus callosum [dysgenesis (malformation) of the corpus callosum]. If you start in the encoder with a search for dysgenesis, your options are gonadal, renal, reticular, and tidal platelet—but there is no option of brain. So, you must start with malformation, then spell out the condition “corpus callosum” to arrive at the final ICD-10 code Q04.0. Your healthcare organization might require you to query for the physician to state “dysgenesis malformation of the corpus callosum,” so check with coding to understand the pediatric coding rules.
Uncommon procedures, too
Pediatric patients are often born with congenital anomalies not often seen in the adult population, requiring minor or major procedures, and these can trip up CDI specialists, too.
For example, gastroschisis is a birth defect in which a baby is born with its organs (typically the intestine) outside of its body due to their abdominal wall not forming completely in the womb. A procedure is performed to repair the defect, sometimes involving a silo, or bag, which pulls the intestine back through the belly button and inside the body. Coding for the procedure looks odd, is not intuitive, and can trip up even an experienced CDI reviewer.
Surgical spinal procedures involving cages, laminectomies, and fusions, particularly with anterior AND posterior approaches, are frequently miscoded (note: an anterior and posterior approach performed during the same procedure results in a much higher paying DRG).
A third example is debridement. These are often miscoded as excisional, when a close review of the operative note shows that no tissue was excised (note: in some cases, the physician did perform an excisional debridement but did not document it. In these instances, you should query).
Three tips for pediatric CDI success
Some final takeaways to ensure CDI success in your pediatric service line or facility.
Implement the buddy system
You need to have good collaboration with your coders. So, Love says you must believe in the buddy system. Pick a seasoned coder you can call on for very tough cases. This is like “phone a friend,” a trusted professional you can call when you’re truly stuck on a tough case.
Just be careful not to be too dependent on your buddy. Exhaust your resources, including your ICD-10-CM Manual and AHA Coding Clinic references, peer reviewed resources like UpToDate, and Google, before “phoning a friend.” Write down everything you’ve attempted to ensure you’ve given it your all and include snippets from your encoder pathway. Show these to your buddy to give them a clear starting point for assistance. Coders typically need to hit productivity marks, and too frequent interruptions may harm their performance.
Also, if you are a CDI professional you need a CDI buddy, too—someone who understands pediatric coding guidelines by providing a secondary review (after exhausting resources prior to initiating contact with a coder buddy) or provide follow-up reviews when the initial pediatric CDI reviewer is not available.
Stay cognizant of frequently missed diagnoses
The list of diagnoses to watch for in the pediatric setting is quite long, but here are Love’s top five:
- Neonatal sepsis
- Acute respiratory failure–hypoxic, hypocapnia, or both
- Respiratory distress syndrome, Type 1
Another condition frequently missed is holoprosencephaly (HPE), the failure of the prosencephalon, or forebrain, to develop normally. Patients with moderate to severe HPE unfortunately typically do not live long, but the condition is an MCC. A physician may not write the diagnosis, but nurses may be documenting motor impairment in the infant and an excess of intensive care.
- Quiz your staff
Develop a quiz for new pediatric CDI staff, and even for veteran reviewers who are moving over to the pediatric service line. Use this to gauge their pediatric acumen, and know that they will continue to learn on the job. Love recommends a 20-question quiz, a mix of easy, medium, and challenging questions, where getting 15 out of 20 correct equates to a good score. This allows you to tailor your education and track progress. Use clinical scenarios and ask the CDI professional to identify query opportunities or locate Coding Clinic references.
Don’t be afraid to mix in a few difficult cases. Even if everyone gets them wrong, such cases can illuminate good critical thinking and indicate a willingness to perform research, which are keys to success in this setting (a tough case is coding COPD with the ICD-10-CM Manual only).
About Sandra Love
Sandra Love, BSN, RN, CCDS, CCDS-O, CPC, is senior manager of CDI for Norwood. Sandra has extensive experience in CDI including but not limited to pediatrics and outpatient. Contact her at firstname.lastname@example.org
About the author
Brian Murphy is the founder and former director of the Association of Clinical Documentation Integrity Specialists (2007-2022). In his current role as Branding Director of Norwood he enhances and elevates careers of mid-revenue cycle healthcare professionals.
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