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infusions/drips/hydrations with no stop time

  1. Default infusions/drips/hydrations with no stop time
    Medical Coding Books
    I code and bill the facility side for the Energency Department

    Is it appropiate to charge for an infusion without a stop time but eligible documentation that the drip was still running?

    My expample is: patient has a nitro drip and the nurse documents the start time and every 5-10mins for the next 2hrs she documents the patients vitals and the rate the drip was infusing. The nurse has no specific stop time but she does have very specific progress notes every 5-10 minutes of the rate on infusion for the nitro for 2 hours. Is it acceptable to charge 2 hrs for this infusion since there is clear documentation the drug was infact infusing for 2 hours? although she did not document when the infusion stopped can I charge for what she did document up to her last progress note?

    I sometimes have the same situations with hydrations, the nurse will document when the hydration started and make progress notes through out the chart that the hyrdration is "infusing well" but no stop time, can I charge for the last documented time that we clearly know the hyrdation was still infusing?

  2. Default
    As long as they are documenting, you can go as far as the documentation goes. Obviously if they state hung "whatever" at 345 and never give a stop time or any other documentation stating it was running past the 15 minutes, then you code as a push. Same with hydration.. if they state hydration started at say 1200 and at 1216 say it is still running, but no other documentation or stop time, then you don't code it. You can count as far as the documentation allows. Hope this helps.

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