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Establish nursing documentation standards for new drug administration codes

APCs Weekly Monitor, March 24, 2006

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Establish nursing documentation standards for new drug administration codes

QUESTION: I'd like your opinion on a proposed protocol for our hospital. We are having a difficult time getting our ED nurses to document start and stop times on infusions. One suggested solution was to use the clinical standard protocol that the nurses use for drug administration.

For example, their protocol states that an infusion of a certain drug is always run over one hour. But since the nurse hasn't documented a stop time, is this protocol acceptable to support a charge for an infusion? Can we use this clinical standard as our hospital guidelines, or must the duration of infusion time be documented in the medical record?

ANSWER: There are many reasons (beyond just coding) that a medical record should reflect the start and stop times for invasive procedures. It is common practice for nursing professionals to record the initiation and discontinuation of an infusion. Most facilities do not have a problem recording this information.

The wording of the question appears to refer to an IV piggy back (IVPB). This is a common problem in facilities because the time at which a IVPB ends is not always recorded in the nursing notes or the medication administration record. Some nursing professionals have stated that the order and start time are sufficient from a care provider perspective.

Unfortunately, with the change in coding rules to new time-based codes, the lack of a stop time has created a compliance conundrum for HIM staff. From a conservative perspective, you should not code the IVPB when proper documentation is lacking. On the other hand, this omission not only creates an inaccurate claim, but provides CMS with an incomplete picture of the patient's total care.

Some facilities have sent the medical record back to the patient care area and requested documentation of the discontinued time. The results were poor because in most instances the caregiver cannot remember and did not note the time in the first place.

Some facilities have proposed using a "standard" unit of time as you have suggested. We do not recommend you adopt this as a standard of practice, as this will lead to the belief that it is not important to document the discontinued infusion time. But on an interim basis, this may work as a compromise for correct coding and may provide an accurate claim picture to CMS until you can instruct nursing staff to record the time, and revise forms to allow for proper recording of the time.

Consider the following when establishing an interim standard:

• Based on Transmittal 785, we now know that the correct way to code/charge infusion time is to calculate the total duration by adding together the amount of time that each IVPB bag takes to infuse. Hospitals should not include in their reporting the time that may elapse between establishment of vascular access and initiation of the infusion.
• An individual IVPB bag often takes less than a full hour to infuse. Therefore, it is inaccurate to code/charge each IVPB intermittent infusion as one full hour of infusion. Time based codes C8950 and C8594 must indicate 16--60 minutes of the infusion or chemotherapy event.
• It is a more accurate practice to count each IVPB (intermittent infusion therapy) as 31 minutes, if you do not document the actual duration in the record.
• Infusion standard of care supports the presumption that a typical IVPB takes 30--60 minutes to infuse.
• The reason for counting 31 minutes instead of 30 minutes is because the code for additional infusion time requires it to be more than 30 minutes. To report time-based codes C8951 and C8955 you must have documentation of infusion or chemotherapy for the subsequent hour(s) of 31 minutes or greater.

Note that while these strategies may help in the interim, facilities must strive for complete, compliant, and accurate documentation to support infusion and injection charges. As CMS gathers data and contemplates paying by hour for 2007, the documentation must be crystal clear along with billing data to ensure APC revenue integrity.

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