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Drug Infusion Documentation

  1. #11
    Default Additional documentation question
    Medical Coding Books
    How do you code if the nurse indicates the start time and then documents the infusion ran for 3 hours, but no stop time is indicated? Can that be coded as infusion?

  2. #12
    Default
    Unless you have an in house policy that insists on the documentation of a stop time on the MAR, there is enough documentation to code the infusion. It may be difficult to code multiple infusions and distinguish between sequential and concurrent infusions with a narrative note.

  3. #13
    Default Re: Drug infusion documentation
    is it appropriate to downcode to push if stop time is not documented? i have worked in three hospitals and all three have varying viewpoints on this issue. Any thoughts?
    Pat A. Trautner, CCS/CPC/CEDC/CHONC

  4. Default
    Quote Originally Posted by ptrautner View Post
    is it appropriate to downcode to push if stop time is not documented? i have worked in three hospitals and all three have varying viewpoints on this issue. Any thoughts?
    Absolutely it is appropriate. If you do not have a stop time or documentation showing it was at least 16 minutes, then you can code as a push.

  5. Default infusions
    I can't really chime in well with all this except to say for here where I work we can not down code infusions to pushes (unless it is 15 minutes or under), if we have an infusion and can't figure out the time by what is on the med sheet and nursing notes (if no stop time is on med sheet) then we send back to 1 of 2 nurse's in the ED and they either put the stop time if they can tell or it gets held till the nurse that was on duty for that pt comes and puts the stop time if the nurse is going to be gone too long for us to hold then it doesn't get coded..alice

  6. #16
    Default Invalid Hydration and Infusion Stop Times
    I work in very busy ER and we are struggling with RNs documenting stop times. The flip side to instructing the RNs to enter stop times is that they are entering them when they have time to document and not necessarily when the infusions and hydrations are completed. I understand the time requirements for each and understand that if a hydration does not have a stop time, it is not billed and if an infusion does not have a stop time, it is billed as an IVP. What do you do if an infusion and/or hydration has an invalid/inaccurate stop time? Is the infusion downcoded to an IVP or not billed at all? Sometimes they have a rate which makes it obvious that the stop time is invalid. If the order specifies a time - say 1 hr - but the stop time is 2-3 hours later, is it still acceptable to charge more than 1 hr?

  7. Default
    Quote Originally Posted by DelMarEs View Post
    I work in very busy ER and we are struggling with RNs documenting stop times. The flip side to instructing the RNs to enter stop times is that they are entering them when they have time to document and not necessarily when the infusions and hydrations are completed. I understand the time requirements for each and understand that if a hydration does not have a stop time, it is not billed and if an infusion does not have a stop time, it is billed as an IVP. What do you do if an infusion and/or hydration has an invalid/inaccurate stop time? Is the infusion downcoded to an IVP or not billed at all? Sometimes they have a rate which makes it obvious that the stop time is invalid. If the order specifies a time - say 1 hr - but the stop time is 2-3 hours later, is it still acceptable to charge more than 1 hr?
    As far as the order thing goes.. you do not code off of an order.. you code by what was actually done.

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