Wiki Facility OB Triage Coding Documentation

[amneske]

Hello!

I am working on OB Triage accounts from the facility side and have noticed that many of them do not have any documentation from a provider. Often I see an OB triage note from a nurse stating the issue, such as “reduced fetal movements” and I see a NST was performed , but I don’t see documentation that the patient was seen by anyone other than the nurse. Is the OB triage note enough to code the diagnosis from when billing for the facility?
Thank you!

 

[nielynco]

Hello!

I am working on OB Triage accounts from the facility side and have noticed that many of them do not have any documentation from a provider. Often I see an OB triage note from a nurse stating the issue, such as “reduced fetal movements” and I see a NST was performed , but I don’t see documentation that the patient was seen by anyone other than the nurse. Is the OB triage note enough to code the diagnosis from when billing for the facility?
Thank you!

What does your procedure protocol say? This should be addressed. If only facility resources were used, I believe you must have a diagnosis that was confirmed by a provider. Whether the RN is sufficient in this case, should be addressed in your protocols. If not, it should be. Is she coming from to triage from another provider outside of the hospital? In that case you can use that diagnosis. If she is self presenting I do think a qualified provider must be the one to assign the diagnosis.