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Nursing Documentation Requirements

  1. Question Nursing Documentation Requirements
    Medical Coding Books
    I am in need of nursing documentation requirements for infusions. Our ED nurses are refusing to document start and stop times and I need information to review with them. thanks.

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    I also need this as we begin battle with our nurses over their documentation. Already, nursing administration is crying about the impact this is going to have on their staff if they have to document start and stop times. I need something to prove to them that this is required.

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    We can not charge for infusions if there is no start and stop time.......there is a site that i will find and post that has the rules for documentation

  4. #4
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    I am definitely no expert in this area but I know for sure that there is an abundance of information regarding this as you can't properly code infusions/injections without the start/stop time if you want to be fully imbursed. The codes themselves are defined by the amount of time spent (ie initial, up to 1st hour, each additional hour, etc). For starters, have them read the CPT coding book (on page 487 for 2010 version). This clearly states the coding guidelines for these procedure codes. Also you may want to reiterate to them that, as coders, we can not code what is not documented so if it is not there, then the hospital/clinic is not going to get paid for it. If you still can't win with them, I'm sure that if you go to administration, surely they will understand the importance of this. Below is also a website that has some helpful hints about coding for these.

    http://www.irminconline.com/document...0Infusions.pdf

    I hope this helps you out
    Last edited by LTibbetts; 01-25-2010 at 11:48 AM.

  5. #5
    Location
    Columbia, MO
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    12,837
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    Quote Originally Posted by Eena View Post
    I also need this as we begin battle with our nurses over their documentation. Already, nursing administration is crying about the impact this is going to have on their staff if they have to document start and stop times. I need something to prove to them that this is required.
    I ran into this as well and what I fail to understand is the nursing schools teach this as a part of their nursing curriculum. So I would say do what I did and go to the nursing school nearest to you and ask for a copy of the instructions on documentation of IVs. It was a good feeling to hand that over to the nursing supervisor.

    Debra A. Mitchell, MSPH, CPC-H

  6. #6
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    Touche, Deb, Good for you! I would have loved to see their faces.....What a brilliant idea!

  7. #7
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    you just have to remember if it is a time based code and there is no stop time you cannot bill it and if you count how many are not documented over the course of a year and dollars that are left on the table..they may see the importance of the documentation.
    Pat A. Trautner, CCS/CPC/CEDC/CHONC

  8. #8
    Location
    Greater Portland (Maine)
    Posts
    129
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    I agree with showing them the financial losses attributable to uncoded infusions. In this economy, you shouldn't be leaving so much money on the table. The nurses should understand that there really is no choice in the matter.
    RCBartholomew, CPC-H, CEDC

  9. #9
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    I approached our ER nursing supervisor and explained we were potentially losing hundreds if dollars a day of lost revenue if the nursing staff does not document start/stop times. It worked! Our nurses do an awesome job at it now!! Money talks

  10. #10
    Location
    Montgomery, AL
    Posts
    11
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    Quote Originally Posted by mitchellde View Post
    I ran into this as well and what I fail to understand is the nursing schools teach this as a part of their nursing curriculum. So I would say do what I did and go to the nursing school nearest to you and ask for a copy of the instructions on documentation of IVs. It was a good feeling to hand that over to the nursing supervisor.
    I can answer this question because I am a nurse and the answer is no. The standard of practice is to document the drug/dosage/route, etc.given and the time it was hung. Not documenting the stop time is a billing issue and has nothing to do with patient care. Educating the nursing staff about missed revenue opportunities by not documenting the stop time will go a lot further than trying to one over them, especially when they are within their standard of practice. Sorry to be so "snippy", but I don't like to see these types of posts about nursing.
    Carol Fowler, CPC-H, CCS

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