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
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