Compliance Monitor, June 9, 2006
Q:I understand nursing documentation can not be used to support codes, however if you are looking at ER documentation and the physician stated he/she had review nurse's notes and agreed with documentation, does that make the nurse's notes supporting documentation?
I feel it does as the physician has referred to the documentation.
My medical records department, however, feels that unless the physician specifically mentions each sign and symptom in nursing notes, it is not codeable. Who is correct?
A: Your Medical Records Department is correct, nursing department documentation cannot support codes. If the physician agrees with the nurse's documentation and that documentation is necessary for coding, he or she must write it.
We can not assume what the physician means when he or she indicates that he or she "agrees with the documentation." Agreeing with the documentation may mean in general terms and not "in fact." We alleviate "assumption coding" by placing the responsibility on the physician to write his impressions/diagnoses.
Thanks to Victoria Druding, RN, PhD, LHCRM a compliance officer with Zavata, Inc. in Conshohocken, PA for answering today's question.
- Study: Almost half of nurses are thinking about leaving the profession
- What does case-mix index mean to you?
- Fracture coding in ICD-10-CM requires greater specificity
- Differentiate between types of wound debridement
- Complications from immobility by body system
- Pneumonia with a negative chest x-ray: Clinical diagnoses, physician documentation, and coding guidelines
- OB services: Coding inside and outside of the package
- Don’t forget the three checks in medication administration
- What is the difference between an IPA and a medical group?
- Note similarities and differences between HCPCS, CPT® codes
- Bill and charge for supplies correctly to reduce risk and minimize lost revenue
- QA:Coding multiple initial infusions
- Seven tips for slashing ED wait times with limited resources
- Q&A: Query for "Type 2 injury"
- Q&A: Coding using suspected, probable diagnoses
- Q&A: Coding for transplant complications
- Note from the Instructor: Review of hospital inpatient mental health services payable under the inpatient psychiatric facility prospective payment system (IPF PPS)
- Increase patient satisfaction by improving your discharge process
- HIPAA Q&A: Maintenance of medical records after physician death
- Don't underestimate the importance of good documentation