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Drug Infusion Documentation

  1. #1
    Default Drug Infusion Documentation
    Exam Training Packages
    I am struggling with the documentation that is required to code a drug infusion specifically if a stop time is required? Is it acceptable to code documentation with an MD order stating a rate and duration along with nursing documentation stating gave without any further documentation stating completed and or a stop time?
    Thanks for your help.

  2. #2
    Location
    Columbia, MO
    Posts
    12,561
    Default
    no a start and stop time must be documented.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    Location
    Louisville, KY
    Posts
    1,101
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    This is a battle for hospital coding staff. One of our nurse managers summed up my sentiments on this: "documenting this is Nursing 101". The catch is, it is nearly impossible to convince the practicing nurses that this is a requirement. I realize the ER can a hectic place to work, but solid documentation practices only support quality care and proper reimbursement. Driving that home is not an easy task.

    Are there any hospital groups that have successfully forced the issue and had positive results? I'd love to hear your methods.

  4. Default Same Here
    Kevin,
    That still seems to be a problem at a lot of the places I've looked at too, along with the wildly varying Levels. I've seen a couple of documentation tools advertised for infusion documentation. Kind of T-system for Infusion time, meds etc. Have your or anyone seen the use of a tool. I realize you can have a great tool, but getting nurse cooperation is another story. Another reason why I like the coder right in the ED to track down this info.

    Jim

  5. #5
    Default
    I have noticed that regular meetings/teleconferences with the ED nurse manager improves nursing documentation for a short time. Using an EMR with software that prevents the disposition of the patient without
    the infusion start/stop times has been helpful.

    A method that I have used for implementing bundlles for VAP, DVT, CLABSI during those grueling 12 hour nursing shifts involves the Charge Nurse (CN) checking for compliance. Before the patient is transferred or discharged or at the end of shift, the CN should observe for complete injection/infusion documentation. Proper documention leads to increased reimbursement and possibly better staffing with an increased budget. When the nurses give report at the end of the shift, a chart check of the orders as well as the MAR with infusion documentation should be completed.

    Nobody likes to be the chart police, but the peer pressure seems to work and eventually the documentation becomes second nature. Perhaps the process could be a QA project for the nurses. I should go away, now.

  6. #6
    Default
    Thanks for your responses....Although I would appreciate specifics on how you actually handle these drug infusions that lack documented stop times. Do you code the drug infusion down to a lower level of a drug push or do you not code the infusion at all? If the drug infusion has been coded without proper times noted have there been compliance issues that you all have run up against?
    Again thanks for your support.

  7. Default Right
    The other side of this issue is compliance. without start stop times drug infusions should be down codeed to IV Pushes. If that is not happening with all of the auditors out there these days, there is a real concern. I believe, but I'll defer to my facility side colleagues, that without start and stop, and you need 1/2 hour at least, hydration is not supposed to be coded at all. I believe one of these was on one of those OIG lists. So in some hospitals there is a loss of revenue, in others real compliance risk.
    I know some EDs have Scribes who basically make sure physician documentation is complete. I wonder if this should be happening on the nurse side as well.

    jim

  8. Default
    Quote Originally Posted by jimbo1231 View Post
    The other side of this issue is compliance. without start stop times drug infusions should be down codeed to IV Pushes. If that is not happening with all of the auditors out there these days, there is a real concern. I believe, but I'll defer to my facility side colleagues, that without start and stop, and you need 1/2 hour at least, hydration is not supposed to be coded at all. I believe one of these was on one of those OIG lists. So in some hospitals there is a loss of revenue, in others real compliance risk.
    I know some EDs have Scribes who basically make sure physician documentation is complete. I wonder if this should be happening on the nurse side as well.

    jim
    Jim you are correct. For hydration without a stop time, you must have documented at least 31 minutes for hydration. Otherwise, you do not code it at all. You could have a note that says 0800 NS hung at 175 cc/hr infusing well 0835 NS infusing well and the no other note then you can code at minumum the hydration for one hour. However, if there was no second note to that scenario and no other stop time reported, then sorry, it can't be coded.

  9. #9
    Location
    Greater Portland (Maine)
    Posts
    129
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    At our facility, we use a daily Excel spreadsheet to document each time we have to downcode (drug infusions down to pushes) or not code at all (hydrations with no down times). These daily ED spreadsheets get sent to the ED Nurse Manager, our MD chief and HIM Director. They each know exactly how many dollars are lost in these instances. We also use this spreadsheet to document when lack of physician documentation resulted in a lower E/M level. Nowadays, we can't afford to be leaving money on the table, so there is a heightened awareness of the value of this information and follow-through occurs regularly. Our nurse manager also uses this feedback for annual reviews. We have been doing this for over a year and a half and it seems to be making a difference.
    RCBartholomew, CPC-H, CEDC

  10. #10
    Default
    At this point the feed back from my facility is that we are able to code a drug infusion as administered by combining the documentation from the electronic MD order including a rate and time with the nurse stating gave and a start time even if this lacks a stop time and or a completed notation. I am being told that unless there is additional notes stating otherwise (infiltration, rate change, ect...) that we can assume it is administered as ordered and completed. I am struggling with coming to terms with this for I am CPC , CPC-H credentialed and within my training I have been taught that without an actual stop or completion time hydrations and drug infusions are either down coded or not coded at all. I do lack first hand experience with this and we do have experienced coders in our department although there has not been much professional CPC training for our facilty doesn't recognize CPT certification. The department is in the process of putting together a policy for injections and infusions and hopefully this will include documentation requirements. I will feel more comfortable to have a set policy.
    Once again thanks for the input.

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