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.
- ICD-10 Trainings
- Comprehensive Courses
- CPC (Certified Professional Coder)
- COC (Certified Outpatient Coder)
- CIC (Certified Inpatient Coder) NEW!
- CRC (Certified Risk Adjustment Coder) NEW!
- CPB (Certified Professional Biller)
- CPMA (Certified Professional Medical Auditor)
- CDEO (Certified Documentation Expert – Outpatient) NEW!
- CPPM (Certified Physician Practice Manager)
- CPCO (Certified Professional Compliance Officer)
- VIEW ALL CERTIFICATIONS
Coding / Billing Solutions
- Audit / Compliance Solutions
Job Experience / Apprentice Removal
News / Discussion
- Other Resources
- Book Store
- Log In / Join