Health Information Management

Work with your FI to determine drug administration documentation requirements

APCs Insider, September 22, 2006

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Work with your FI to determine drug administration documentation requirements

QUESTION: Our facility is debating the OPPS injection/infusion billing requirements-specifically documentation of time as required by CMS. Some FIs state that we must document the infusion start and stop time in order to bill the correct code (for example, one hour, additional hours, IV push codes). However, there is no CMS guidance on this point. At our facility, we are devising different ways to document time in order to bill and support the correct code.

For example, we could document the specific drug, route of the drug, infusion duration (i.e., to be infused over 30 minutes), and the start time. All nurses would initial that they have infused the drug for the duration specified and also initial the start time. If a nurse is unable to infuse the drug for the time ordered, he or she can then document that in the record. Internal and external auditors could use the documented time to determine whether staff billed the correct code.

It is not nursing practice to go back and document the stop time of an infusion-rather, they set the pump and document the start time and the duration, from which coders can easily determine the correct code. What are your thoughts on our process?

ANSWER: This question is definitely something providers must investigate with individual Medicare contractors. A query to one FI (TriSpan) in April, 2006, asked whether providers must document a specific start and stop time or whether total time was adequate. The answer indicated that they "do not have a local coverage determination (LCD) that specifically addresses documentation of infusion services; there are no set regulations. Therefore, the documentation method chosen would be left at the discretion of your facility's guidelines."

Instructions related to outpatient therapy services give support to documentation of either start/stop time or documentation of total time as an appropriate method of documentation. The CMS Claims Processing Manual, Chapter 5, section 20.2, states "The beginning and ending time of the treatment should be recorded in the patient's medical record along with the note describing the treatment. The time spent delivering each service, described by a timed code, should be recorded. (The length of the treatment to the minute could be recorded instead.)"

You can find the reference on p. 37 of this document:

While this reference is for outpatient therapy-and not drug administration-and CMS instructions do not always remain consistent across services, it does lend support to the idea that either documentation method would be OK.

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