Wiki IV Coding Documentation and Coding Debate

[sheripeters]

Patient presents to the ER with nausea and vomiting x 2 days. Physician orders Hydration of normal saline (dehydration DX) and Zofran IVP and Toradol IVP ordered at 1100. According to the MAR Normal saline was started at 11:15AM and stopped at 1:00 PM. The Zofran and Toradol was given at 11:30 with no stop time.

What would the correct codes be?

Our debate is on the Zofran and Toradol. We think that because documentation on the MAR is "given" at 11:30" then we would need to code it as 96374 (IVP Initial) and 96361 x2 (Hydration).

The question is that if the documentation uses the same administration time even though it is for more than one medication should we code 96374 and 96375 in addition to the 96361x2 instead.

 

[OCD_coder]

You would need to know if the Toradol and Zofran were mixed into a single syringe. I have seen documented as two syringes and a single syringe.

If two syringes were used, you would code the 96374, 96375, 96361 x 2 scenario.

 

[sheripeters]

still confused

You would need to know if the Toradol and Zofran were mixed into a single syringe. I have seen documented as two syringes and a single syringe.

If two syringes were used, you would code the 96374, 96375, 96361 x 2 scenario.

the problem is that in the MAR Summary we do not get any info on how the medications were given except for (mixed,etc) we are only told medication given @TIME how IVP and by whom.

example : potassium chloride + Sodium Chloride 0.45% 500 mL
given 20mEq@1333 IV (no stop time)
ondansetron (Zofran) 4 mg =2 mL IV Push
given 4 mg@ 1333 IV (no stop)
hydralazine 10 mg=0.5 mL vial IV
given 10@mg@1333 IV (no stop)

sodium chloride 0.9% 1000 mL 500 mL/hr total volume 1000
started at 1300 and stop time 1515
would this be 1. 96374 x1 and 96361 x2

or 2. 96374 x1, 96375 x2, and 96361x2

 

[OCD_coder]

The record is incomplete and I wouldn't code it as is.

Potassium chloride is typically run over an hour or more and that is the purpose of the saline - drug administration. I would send it back for stop times as your going to miss a 96365 and a 96367 for two different drugs.

Show them the differences in fees and they'll get it.

example : potassium chloride + Sodium Chloride 0.45% 500 mL given 20mEq@1333 IV (no stop time)
(Suspect 96365, documented as 96374)

ondansetron (Zofran) 4 mg =2 mL IV Push given 4 mg@ 1333 IV (no stop)
(Push or IV? 96375)

hydralazine 10 mg=0.5 mL vial IVgiven 10@mg@1333 IV (no stop)
(Should be 96367, documented as 96375)

sodium chloride 0.9% 1000 mL 500 mL/hr total volume 1000 started at 1300 and stop time 1515
(135 min = 96361 x 2 if potassium not run with saline)