BY TINA R. MCDANIEL CHENG, MSN, RN, CCDS, AND LAUREN PFEIFER, PhD, RN, CCDS
Pediatric patients are not little adults. Due to their unique physiological and developmental needs, children often are diagnosed with medical conditions that differ substantially from their adult counterparts. One difference is that due to their immature immune systems, children are more susceptible to infection (CDC, 2020). They also use energy more quickly than adults, which leads to an increased risk for dehydration and malnutrition. Moreover, children are more vulnerable to serious illness and injury given their engagement in high-risk behaviors (e.g., climbing on furniture, accidental ingestions, reckless driving). All of these factors mean that when hospitalized, pediatric patients are highly acute and often require intensive support and care management planning. There is no such thing as “one-size fits all” when it comes to pediatric case management. Pediatric case managers have the unique privilege to serve as patient advocates, to guide and coordinate service and resource needs and collaborate with families to promote their optimum level of wellness and physical functioning (CMSA, n.d.). In order to accomplish these goals, it is essential that pediatric case managers be able to effectively, appropriately and comprehensively communicate with payers, service providers and family members. To achieve this, it is paramount that case managers and providers recognize the important role that clinical documentation plays in both accessing services and the reimbursement process.
While many case managers may be familiar with the important role that utilization review managers (UM) play in the prior authorization and reimbursement process, fewer know about the responsibilities of clinical documentation integrity (CDI) specialists. Like utilization managers, CDI specialists meticulously review encounter notes to ensure the documentation accurately reflects the complexity of care, intensity of services being rendered and provides a clear illustration of the individual’s unique clinical circumstances. Utilization review managers are dependent upon high-quality and accurate documentation in order to justify a patient’s level of care assignment and advocate for services and procedures. While the role of the CDI specialist slightly differs, both are dependent upon the clinical documentation accurately and fully capturing all clinically significant conditions and performed procedures. Accurate clinical documentation is essential as it influences clinical care, quality reporting, hospital benchmarking and finances.
Presently, hospitals face extreme challenges as they attempt to provide high-quality, safe and technologically-advanced patient care while addressing rising costs and unprecedented staffing challenges. Pediatric healthcare organizations also face a unique set of obstacles as they try to justify service needs and capture a patient’s severity of illness using a coding system and payment structure built for adults. Since 1999, the United States has used the International Classification of Diseases (ICD) code set published by the World Health Organization to classify and report clinical diagnoses and procedures. The ICD code set is the global standard for reporting and categorizing health-related conditions. The objective is to have a consistent and standardized code for every existing medical condition. In the current iteration, ICD-10, there are more than 70,000 diagnosis codes and 78,000 procedural codes. By using a standardized classification system, coders are able to translate documented conditions and procedures in the medical record into alphanumeric codes understood by payers. This system allows organizations and overseeing regulatory bodies to collect and analyze robust data regarding the types of conditions being treated, which in turn promotes improved measurement of the quality, safety and efficacy of care delivered. Moreover, the use of ICD codes improves the monitoring of resource utilization, financial performance and claims processing for reimbursement (CMS, n.d.).
CDI programs began in 2007 after the Centers for Medicare & Medicaid Services (CMS) began using Medicare Severity Diagnosis Related Groups (MS-DRGs) for reimbursement. In the MS-DRG system, a patient is assigned a principal diagnosis (ICD-10 code) to capture the reason necessitating the hospitalization. Each code is assigned a relative weight score for reimbursement and an estimated length of stay. Since the MS-DRG system was developed with the Medicare population in mind, diagnoses, reimbursement rates and anticipated length of stay calculations are often insufficient in accurately and fully capturing conditions specific to pediatrics. To address this limitation, the APR-DRG system was developed. Like the MS-DRG system, the APR-DRG system also provides hospitals with a relative weight and anticipated length of stay for a patient’s assigned principal diagnosis. However, the APR-DRG also takes into consideration the numerous other factors that influence a patient’s level of severity and risk of mortality. To capture the unique complexities of each patient, individuals with certain co-existing conditions (which in the coding and CDI arena are called “secondary diagnoses”) are assigned a higher relative weight and consequently are reimbursed at a higher amount. To illustrate how certain diagnoses can impact the final coding and reimbursement, a fictitious case scenario is presented below.
A 7-year-old male is admitted to the hospital for worsening PO intake and several weeks of nausea/vomiting. Over the next few days, the attending physician diagnoses the patient with mild malnutrition. The physician documents that the patient has continued to take his three anti-epileptic medications and should be given Diastat if he seizes for over 5 minutes.
While providers have documented epilepsy, no one has specified it as intractable in their progress notes. The patient’s medication administration record and provider comments suggest that this diagnosis should be considered. However, since intractable epilepsy has not been clearly documented, the ICD-10 code will default to the lesser severity diagnosis of non-intractable epilepsy in the final hospital code/bill.
How will this impact the final coding and reimbursement?
Case Scenario Impact of Capturing Intractable Epilepsy Intractable Epilepsy NOT coded Intractable Epilepsy IS coded DRG 421 — Malnutrition, Failure to Thrive and Other Nutritional Failures 421 — Malnutrition, Failure to Thrive and Other Nutritional Failures Principal Diagnosis E441 Mild Malnutrition E441 Mild Malnutrition Secondary Diagnosis G40909 Epilepsy, not intractable, w/o status epilepticus G40919 Epilepsy, unspecified, intractable, w/o status epilepticus Severity of Illness 1 2 Risk of Mortality 1 1 Weight (CMI) 0.6968 0.7188
Secondary diagnoses, like intractable epilepsy, often influence a patient’s length of stay, intensity of services and the amount of clinical resources consumed. When providers clearly document secondary diagnoses in their progress notes, the final coding paints a more accurate illustration of each patient’s unique clinical circumstances, which subsequently improves the hospital’s quality scores and reimbursement for the case. In turn, hospitals are appropriately paid for the incredible care they have been providing all along. In many instances, the difference in reimbursement can be thousands of dollars, which, in turn, pays for nursing salaries, unit expenses (e.g. equipment, linens, electrical and utilities) and specialty services (e.g. nutrition, child life therapists, social workers).
The establishment of the APR-DRG payment model is a helpful first step in the improvement of clinical documentation in pediatrics. However, those of us working in CDI know that we have a long way to go. Unfortunately, pediatric case managers working in UM and CDI continue to face hurdles in their effort to communicate with payers, advocate for services and ensure the medical record appropriately captures the patient’s level of care, intensity of services and severity of illness. The ICD-10 code list used in the United States is maintained and updated by CMS and the American Medical Association (AMA). As the list was designed specifically to maximize efficiencies in the medical claims process for patients with Medicare, the majority of conditions are adult-focused and not always relevant or applicable to the pediatric population. Consequently, CDI pediatric specialists often rely upon DRG-payment methodologies and coding tools designed specifically for adults, which may not capture the full breadth of the pediatric patient’s unique complexities and care needs. In comparison to adults, pediatric patients are physiologically less mature and more susceptible to certain dysfunctions (e.g., AKI, electrolyte derangements, and malnutrition). While a CMI weight assigned to an adult with a particular condition may seem appropriate, the same projected length of stay or assigned severity score may be inaccurate for pediatric patients. Moreover, there remain a plethora of pediatric-specific conditions that still lack a matching ICD-10 code, which means not every clinically significant condition can be accurately captured in the final hospital coding.
To combat these challenges, it is paramount that pediatric CDI specialists focus their attention on education. In addition to supporting providers, CDI specialists may find it useful to conduct educational sessions with utilization managers, discharge planners and specialty groups across case management and the organization. Such education could help spread general awareness regarding the importance of clinical documentation for all clinicians (not just those with prescriptive authority) and promote collaboration among teams to identify strategies for improvement. CDI specialists may find it particularly fruitful to conduct educational sessions for incoming residents and newly hired nurse practitioners, physicians and physician assistants. Likewise, it may help to work more closely with specialists (e.g. nutritionists, feeding team specialists) to review the coding rules that impact whether or not a diagnosis they document in their consultation note will be included in the final hospital coding or not.
As the acuity and complexity of pediatric patient care continues to rise, it is critical that organizations continuously collect and measure important metrics to evaluate the quality of care being provided along with how to better predict resource needs, staff requirements and lengths of stay. Without accurate documentation, the ability to measure trends and conduct benchmark analyses with external organizations is not achievable. Furthermore, inaccurate or insufficient documentation prohibits organizations from identifying opportunities to improve the care and management of the patient populations served within their organization. Failure to accurately document conditions and procedures may lead to the denial of services or hospital admissions and suggest that patients cared for within the organization have falsely low severity and complexity scores. As patient care continues to shift toward the outpatient arena, it is critical that case managers remain actively engaged in both the design and delivery of future care. However, in order to fully advocate for their needs, pediatric case managers should make high-quality clinical documentation one of their top priorities. While the field of CDI may have a ways to go, those of us working in pediatrics rejoice in the baby steps and progress being made along the way…
Case Management Society of America (CMSA) (n.d.). What is a case manager? Retrieved from https://cmsa.org/who-we-are/what-is-a-case-manager/
Centers for Disease Control and Prevention (CDC) (2020). How are children different from adults? Retrieved from https://www.cdc.gov/childrenindisasters/differences.html
Centers for Medicare & Medicaid Services (CMS) (n.d.). Basic introduction to ICD-10-CM. Retrieved from Slide 1 (cms.gov)
Joint Commission (2021). The joint commission sentinel event alert. https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/sentinel-event/sea-39-ped-med-errors-rev-final-4-14-21.pdf
Savage, L. (2017). Pediatric CDI: Building blocks for success. HCPro
Tina R. McDaniel Cheng, MSN, RN, CCDS, is a clinical documentation integrity (CDI) specialist at Boston Children’s Hospital. Prior to this role, she worked as a CDI lead at MetroWest Medical Center in the adult population and has been a certified clinical documentation specialist (CCDS) for 4 years. Tina earned her Master’s in Nursing Education from Notre Dame of Maryland University. She is currently working on a healthcare focused MBA.
Lauren Pfeifer, PhD, RN, CCDS, is a clinical documentation integrity (CDI) nurse at Boston Children’s Hospital. Prior to this role, she worked in ED Case Management and Utilization Management. In 2022, Dr. Pfeifer earned her PhD from Boston College and was one of the first to investigate the relationships among psychological safety, high reliability and safety reporting among nurses. At Boston College, she served as a research fellow and co-taught courses on organizational leadership. In 2023, Dr. Pfeifer became a certified clinical documentation specialist (CCDS). Organizationally, she is a member of the High Reliability Implementation Committee and Magnet Champion Group. She is a member of Sigma Theta Tau, the Society of Pediatric Nurses (SPN) and the National Pediatric Nurse Scientist Collaborative (NPNSC).
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