Are Pediatric Emergency Departments Undervaluing Their Care?

Jim Strafford

Jim Strafford , CEDC, MCS-P


Published August 17, 2013

Proper coding of emergency department (ED) services is crucial to hospital reimbursement. And with expanded coverage under Obamacare expected to drive increased patient volumes, compliant but appropriate patient acuity coding will be more important that ever. However, documentation and coding reviews conducted by our team at Healthcare Administrative Partners suggests that providers at pediatric EDs have a tendency to undervalue some of the services they provide.

The guidelines of emergency department charting and coding (which include History/Physical and Medical Decision Making) are governed by CMS and CPT requirements that span all ED settings. However, pediatric EDs differ significantly from their generalist counterparts in terms of acuity metrics, type of care rendered and documentation challenges. For example, an injury that might result in prescription medication for an adult usually results in an over-the-counter medication for a child, because many prescription-strength painkillers are not suitable for children. And in terms of documenting key elements of the patient history, any pediatrician can attest that three-year olds simply aren't very good historians.

We believe there are several reasons why the coding done in pediatric emergency departments may not accurately reflect the acuity of the cases seen. For one, treatment protocols for kids are often different than those for adults and may not be fairly represented in Medical Decision Making (MDM) guidelines. Furthermore, there are significant risks and challenges in treating children that must be thoroughly documented so that the coder can assign the proper level of care.

In reviewing hundreds of pediatric ED charts, we identified the following as common sources of coding variances from adult ED services. While the following are most salient to pediatric EDs, many points also apply to pediatric care delivered in general EDs.

Critical Care for Cardiovascular and Respiratory Disorders

Pediatric EDs have few patients presenting with chest pain, COPD and other complaints of the middle-aged and elderly. This results in lower rates of admission and lower acuities overall.

But this does not mean that pediatric EDs don't provide high-level and even Critical Care for cardiovascular and respiratory problems. Such cases typically involve children with congenital defects or chronic conditions that have exacerbated.

What's more, the number of children appearing in EDs with respiratory complaints often exceeds the number of adults. Acute exacerbation of asthma is a common reason for ED visits and often justifies Critical Care. But our review of charts indicates that physicians in pediatric EDs often do not document these cases as such.

Let's say a child is in respiratory distress. There is a risk of respiratory system failure and a need for immediate and ongoing intervention. The patient receives multiple nebulizer treatments, oxygen, IV medication and pulse oximetry monitoring. When such care lasts at least 30 minutes and is provided by the attending physician, this qualifies as Critical Care and should be documented accordingly.


Our review found a tendency for providers to code childhood injuries at a lower level than the same injury in an adult. We feel this is a mistake for several reasons. For one, children and adults usually receive similar treatments (for example, pain relief, x-rays and immobilization for a sprained ankle). Furthermore, the risk related to a childhood injury can be greater than that of an adult injury in terms of bone growth and other sequelae.

Providers can help by documenting all risks related to the injury. Where applicable, charts should reflect review of diagnostics, immobilization, medication and specialist consults.

Coding for fractures is rare in the pediatric ED, but should be done when the attending physician (and not the orthopedic resident) provides restorative care.


Many children who report to pediatric EDs with fever are treated with non-prescription acetaminophen. We have seen that physicians will properly document very specific instructions for dosage strength and timing. However, a strict interpretation of the Table of Risk (which categorizes management with over-the-counter drugs as "Low Risk") might not result in selection of the code that best reflects the very real dangers associated with childhood fever. Often, these are very sick kids requiring significant treatment.

When applying such criteria, coders should weigh medical necessity and the risks unique to children — especially toddlers and babies. Providers should document potential risks to help ensure that the appropriate CPT level is coded.

Other Considerations

Sadly, many children visit EDs as a result of abuse. Once again, the E/M tools might not adequately reflect the complex and sensitive nature of these visits. ED providers should clearly document the entire visit, including involvement of other health care providers and caseworkers.

In Summary

Pediatric EDs often differ from general EDs in terms of clinical and payer mix, presenting problems and course of treatment. Based on our review, there is a tendency to undervalue conditions and treatments unique to pediatric ED patients, because often the best course of treatment is quite different from that for adults. Providers must clearly document all conditions and risks of treatment so that the coder can properly report ED levels.

For questions or updates on this review, please feel free to email Jim Strafford at

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