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when is no documentation ok?

  1. Question when is no documentation ok?
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    I have always been told if it is not documented it did not happen. At this current practice I am at I find little to know documentation on some charges that have been submitted for pymt to ins. Example pt not scheduled but comes in for Xolair inject. pt brings in med and we charge just the 90772. There is nothing documented other than the superbill in the pt's chart. The nurse noted pt did fine and the amount and vile number. Is this Documentation?
    Susie Savage, CPC

  2. #2
    Location
    Jefferson City, MO
    Posts
    33
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    I work in a hospital that does injections all the time. The main thing I ask from the nurses is the drug name, route given, reason for adminisering drug and time it was given. If the drug is brought in by the patient and not gotten at our pharmacy the nurses will also note this. Without at least this information, I do not charge until missing information is clarified by the nurse/doctor.

    Hope that helps.

  3. #3
    Location
    Greeley, Colorado
    Posts
    2,045
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    Quote Originally Posted by ssavage View Post
    I have always been told if it is not documented it did not happen. At this current practice I am at I find little to know documentation on some charges that have been submitted for pymt to ins. Example pt not scheduled but comes in for Xolair inject. pt brings in med and we charge just the 90772. There is nothing documented other than the superbill in the pt's chart. The nurse noted pt did fine and the amount and vile number. Is this Documentation?
    I think at the very least the nurse needs to note WHERE s/he placed the injection...
    Lisa Bledsoe, CPC, CPMA

  4. #4
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    I work at an Oncology practice and we have many patients that come in every week for injections only. First, this DOES have to be documented in the patient's chart. Period! If you are ever audited and have no documentation in the patient's chart in regards to a service was performed, not only will you have to give back every dollar you were paid, you would be subject to huge fines and penalties. Very bad.

    But, we're not talking about a dictated note here or anything. We have a "flow sheet" for our injections where at the top of the page it has the patient's info- name, dob, chart #, what drug is being injected and the diagnosis for why they are receiving the injection. Then underneath are columns for each visit where the date of service, patient's vitals (weight, bp and temp), dose, injection site and time are documented along with the nurses initials. There are probably 20 lines on each side of the page, so this way we have a clear record of what service was performed for each injection. We do this for ALL our injections, even when it is the patient's own supply. For injections like Procrit, we also note the hct/hgb level which shows the medical necessity for the injection.

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