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Thread: Documentation for time based codes

  1. #1

    Default Documentation for time based codes

    AAPC: Back to School
    Would anyone be willing to share how they have the nursing staff document time. Maybe a form that could be used or direct me to a site that a form could be obtained.

  2. #2


    With shrinking budgets, nursing staff is expected to do more with less resources. The nursing documentation deficiencies should be addressed by the nurse manager; s/he can use the information for the staff members' annual evaluations and merit raises. The charge nurse should be responsible for double-checking the MAR before each nurse leaves for the day.

    In ICU, oncoming nurses perform chart checks at the end of each shift with off going nurses looking for missed orders and incomplete MARs.

    We see so much money left on the table when infusion start and stop times are not documented. If you are not getting the documentation you need, can you send the medical record back for clarification? If not, use a spreadsheet to document the codes you are unable to bill with the medical record number, DOS and the assigned nurse for retrospective feedback. If you can add a fee to each non billable service and total with a bold red font, it might get the point across quicker! Submit daily to the nurse manager.

  3. #3

    Smile Thank you

    Thank you very much for responding and I will pursue this further as suggested.

  4. #4


    It is a constant battle but more reimbursement equals a bigger budget and hopefully more nursing staff to care for the patients.

  5. #5
    Join Date
    Apr 2007
    Bettendorf, Iowa


    Most practices have standard forms that nurses fill out as they go along while administering tx and that would include columns for start/stop times. Our nurses hand write them on the administration sheets as they administer tx and then once tx is done they document it in the EMR which is time/date/name stamped.

    Our billing dept goes over each individual tx after nursing has documented. We double check all their information and if there's something missing or out of the norm we address that nurse immediately and have them correct it immediately. The entire billing for that particular day is put on hold til they correct it so that puts alot of pressure on them to get it done right away.

    Really it depends on what type of setting you are in. I'm in an office and able to have face-to-face contact with nursing staff to get what I need. If you're in a hospital or clinic setting it may not be that easy. MOJO is right about showing them on paper how much money they are missing out on when documentation is inaccurate. There's also the risk of fines/recoupment and with RAC audits well underway no one wants to get stuck refunding payments.
    Ruth Long CPC,CHONC

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