Health Information Management

Coding from nurses' notes

HIM-HIPAA Insider, November 24, 2009

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Q. We have been told that coders are not allowed to code from nurses’ notes. Can anyone tell me where I can find documentation of this coding rule?
 
A: According to Coding Guidelines, effective October 1, 2008:
The term encounter is used for all settings, including hospital admissions. In the context of these guidelines, the term provider is used throughout the guidelines to mean physician or any qualified health care practitioner who is legally accountable for establishing the patient’s diagnosis. Only this set of guidelines, approved by the Cooperating Parties, is official.
In p. 8 of the March 2008 Briefings on Coding Compliance Strategies, Lori S. McGuire, CCS, EMT, founder of Simply Coding in Nevada, OH, states: “There are several areas of the record that coders should not use when assigning a code. For example, coders should never code from a nurse’s notes. However, notes that a nurse provides can assist coders who are looking for important clues that might lead to a particular diagnosis. If this information is missing from the physician’s documentation, coders can query the physician regarding a condition that a nurse may have intimated.”
 
Editor’s note: Sandra Sillman, RHIT, PAHM, DRG coordinator for medical record services at Henry Ford Health System in Detroit, answered the previous question in the November issue of Briefings on Coding Compliance Strategies.



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