Question Emergency Department Admit to floor infusion

nipeschon

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I work the cpt coding for the ED accts. A lot of times the pt will leave the Ed with no stop time for the infusion. We will push since one can’t verify if it stopped, got kinked, fell out etc.Would this be correct? We all know if it Not documented it is Not done.
If nursing staff don’t doc. a stop/running etc. How can the coder verify etc.

Ex: Pt in the Ed Dept and left for the unit:
6*15*21
1420-1845
Morphine at 1745
Zofran at 1805
*Rocephin inf at 1815 no Hard stop or running at time pt left for the floor at 1845in Ed acct note. How can one verify it actually stopped w/out proper documentation? From nursing staff
For the ex above I would have done a
96374

96375x1 and w/no stop on the Rocephin a 96375x1
one can’t assume if it ran to the floor at the time pt left w/out any kind of documentation to verify.
We have always if no Hard stop or Continue to floor etc. have always pushed.

Any help would be greatly appreciated 😊
 

nipeschon

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If no stop time is documented, then the only thing you can code is an IV push. This is how we handle these in our facility. We've also been doing a big education push to all of the nursing staff to document both start and stop times in the medical record.
Thank you I thought I was going crazy! Lol
 

thomas7331

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Your facility should give you some internal guidelines or create policies on how these situations should be handled.

The facilities where I've worked would use the last documented time that the infusion was running in the event that no stop time was documented. So in your example, if you had documentation that the infusion was running at the time the patient left the floor but no further documentation, then we would use that time as the stop time. From what I understand, the auditors and payers who reviewed our coding agreed with this approach.

Without a stop time, one facility I worked with would code as a push, but another instructed us not to code the infusion at all if there was no documentation of the stop time or subsequent time when we could verify that the infusion was still running.

Just to add, since you mention 'admit to floor' in the title of your post - if the patient is admitted to inpatient status, it's usually the policy to make the time of admit as the stop time for all infusions. Once admitted, the costs of infusions are generally considered included in the costs of room and board and you wouldn't post any charges for infusions running after admission. Of note, the time of admit would be the time that the order to admit was written by the physician, not the time that the patient was transferred to the floor.
 
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