Corporate Compliance

Nursing documentation to support coding

Compliance Monitor, May 19, 2006

Q:When can nursing documentation be used to support the selection of a diagnostic code? If an E code is further specified in the nursing triage note, can we use that information when selecting the code?

If the physician says diabetes but the nursing documentation adds that it is Type 1 diabetes could we code the Type 1? I have heard that if the facility decides the nursing documentation can be used, it can.

A: Nursing documentation can not be used to assist or support the coding process. Doctors alone are responsible for the diagnosis and therefore the proper code assignment. There is an exception to the nursing concept; however, diagnoses and codes provided by registered nurse practitioners who can bill for services would be a valid as a physician's.

Second, an "E code" describes the circumstances that caused an injury rather than the nature of the injury (Uniform Billing Editor).

And a facility can not determine regarding how coding is done aside from the accepted practice. However, registered nurse practitioners are regulated by the state in which they practice. The rules and laws differ state to state.

Thanks to Victoria Druding, RN, PhD, LHCRM a compliance officer with Zavata, Inc. in Conshohocken, PA for answering today's question.

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