Wiki injury occuring in inpatient facility

[DeniseC]

Can an injury documented only by a nurse be coded with external cause of injury codes?

 

[jonique.dietzen]

If you are coding for an E&M service, the review of systems and the personal/family/social history can be obtained by support staff. Only the History of Present Illness must be documented by the provider directly.

So, I would say if this is a subsequent visit and the provider references back to the nurse's notes for ROS and PFSH, the nurse's documentation would fall under personal history and it'd be OK to add the external cause code. But if this is an initial visit, the documentation of the injury should fall under the HPI and be documented by the provider.

Jonique Dietzen, CPC