# Drug Infusion Documentation



## CCMongillo (Apr 1, 2011)

I am struggling with the documentation that is required to code a drug infusion specifically if a stop time is required? Is it acceptable to code documentation with an MD order stating a rate and duration along with nursing documentation stating gave without any further documentation stating completed and or a stop time?
Thanks for your help.


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## mitchellde (Apr 1, 2011)

no a start and stop time must be documented.


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## kevbshields (Apr 2, 2011)

This is a battle for hospital coding staff.  One of our nurse managers summed up my sentiments on this:  "documenting this is Nursing 101".  The catch is, it is nearly impossible to convince the practicing nurses that this is a requirement.  I realize the ER can a hectic place to work, but solid documentation practices only support quality care and proper reimbursement.  Driving that home is not an easy task.

Are there any hospital groups that have successfully forced the issue and had positive results?  I'd love to hear your methods.


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## jimbo1231 (Apr 2, 2011)

*Same Here*

Kevin, 
That still seems to be a problem at a lot of the places I've looked at too, along with the wildly varying Levels. I've seen a couple of documentation tools advertised for infusion documentation. Kind of T-system for Infusion time, meds etc. Have your or anyone seen the use of a tool. I realize you can have a great tool, but getting nurse cooperation is another story. Another reason why I like the coder right in the ED to track down this info.

Jim


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## Mojo (Apr 2, 2011)

I have noticed that regular meetings/teleconferences with the ED nurse manager improves nursing documentation for a short time. Using an EMR with software that prevents the disposition of the patient without
the infusion start/stop times has been helpful.

A method that I have used for implementing bundlles for VAP, DVT, CLABSI during those grueling 12 hour nursing shifts involves the Charge Nurse (CN) checking for compliance. Before the patient is transferred or discharged or at the end of shift, the CN should observe for complete injection/infusion documentation. Proper documention leads to increased reimbursement and possibly better staffing with an increased budget. When the nurses give report at the end of the shift, a chart check of the orders as well as the MAR with infusion documentation should be completed. 

Nobody likes to be the chart police, but the peer pressure seems to work and eventually the documentation becomes second nature. Perhaps the process could be a QA project for the nurses. I should go away, now.


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## CCMongillo (Apr 4, 2011)

Thanks for your responses....Although I would appreciate specifics on how you actually handle these drug infusions that lack documented stop times. Do you code the drug infusion down to a lower level of a drug push or do you not code the infusion at all? If the drug infusion has been coded without proper times noted have there been compliance issues that you all have run up against?
Again thanks for your support.


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## jimbo1231 (Apr 4, 2011)

*Right*

The other side of this issue is compliance. without start stop times drug infusions should be down codeed to IV Pushes. If that is not happening with all of the auditors out there these days, there is a real concern. I believe, but I'll defer to my facility side colleagues, that without start and stop, and you need 1/2 hour at least, hydration is not supposed to be coded at all. I believe one of these was on one of those OIG lists. So in some hospitals there is a loss of revenue, in others real compliance risk.
I know some EDs have Scribes who basically make sure physician documentation is complete. I wonder if this should be happening on the nurse side as well.

jim


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## eadun2000 (Apr 4, 2011)

jimbo1231 said:


> The other side of this issue is compliance. without start stop times drug infusions should be down codeed to IV Pushes. If that is not happening with all of the auditors out there these days, there is a real concern. I believe, but I'll defer to my facility side colleagues, that without start and stop, and you need 1/2 hour at least, hydration is not supposed to be coded at all. I believe one of these was on one of those OIG lists. So in some hospitals there is a loss of revenue, in others real compliance risk.
> I know some EDs have Scribes who basically make sure physician documentation is complete. I wonder if this should be happening on the nurse side as well.
> 
> jim



Jim you are correct.  For hydration without a stop time, you must have documented at least 31 minutes for hydration.  Otherwise, you do not code it at all.  You could have a note that says 0800 NS hung at 175 cc/hr infusing well  0835 NS infusing well and the no other note then you can code at minumum the hydration for one hour.  However, if there was no second note to that scenario and no other stop time reported, then sorry, it can't be coded.


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## Rita Bartholomew (Apr 4, 2011)

At our facility, we use a daily Excel spreadsheet to document each time we have to downcode (drug infusions down to pushes) or not code at all (hydrations with no down times).  These daily ED spreadsheets get sent to the ED Nurse Manager, our MD chief and HIM Director.  They each know exactly how many dollars are lost in these instances.  We also use this spreadsheet to document when lack of physician documentation resulted in a lower E/M level.  Nowadays, we can't afford to be leaving money on the table, so there is a heightened awareness of the value of this information and follow-through occurs regularly.  Our nurse manager also uses this feedback for annual reviews.  We have been doing this for over a year and a half and it seems to be making a difference.


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## CCMongillo (Apr 4, 2011)

At this point the feed back from my facility is that we are able to code a drug infusion as administered by combining  the documentation from the electronic MD order including a rate and time  with the nurse stating gave and a start time even if this lacks a stop time and or a completed notation.  I am being told that unless there is additional notes stating otherwise (infiltration, rate change, ect...) that we can assume it is administered as ordered and completed. I am struggling  with coming to terms with this for I am CPC , CPC-H credentialed and within my training I have been taught that without an actual stop or completion time hydrations and drug infusions are either down coded or not coded at all. I do lack first hand experience with this and we do have experienced coders in our department although there has not been much professional CPC training for our facilty doesn't recognize CPT certification. The department is in the process of putting together a policy for injections and infusions and hopefully this will include documentation requirements. I will feel more comfortable to have a set policy.  
Once again thanks for the input.


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## djnall (May 25, 2011)

*Additional documentation question*

How do you code if the nurse indicates the start time and then documents the infusion ran for 3 hours, but no stop time is indicated? Can that be coded as infusion?


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## Mojo (May 25, 2011)

Unless you have an in house policy that insists on the documentation of a stop time on the MAR, there is enough documentation to code the infusion. It may be difficult to code multiple infusions and distinguish between sequential and concurrent infusions with a narrative note.


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## ptrautner (Jun 1, 2011)

*Re: Drug infusion documentation*

is it appropriate to downcode to push if stop time is not documented?  i have worked in three hospitals and all three have varying viewpoints on this issue. Any thoughts?


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## eadun2000 (Jun 1, 2011)

ptrautner said:


> is it appropriate to downcode to push if stop time is not documented?  i have worked in three hospitals and all three have varying viewpoints on this issue. Any thoughts?



Absolutely it is appropriate.  If you do not have a stop time or documentation showing it was at least 16 minutes, then you can code as a push.


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## alices (Jun 1, 2011)

*infusions*

I can't really chime in well with all this except to say for here where I work we can not down code infusions to pushes (unless it is 15 minutes or under), if we have an infusion and can't figure out the time by what is on the med sheet and nursing notes (if no stop time is on med sheet) then we send back to 1 of 2 nurse's in the ED and they either put the stop time if they can tell or it gets held till the nurse that was on duty for that pt comes and puts the stop time if the nurse is going to be gone too long for us to hold then it doesn't get coded..alice


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## DelMarEs (Jul 2, 2011)

*Invalid Hydration and Infusion Stop Times*

I work in very busy ER and we are struggling with RNs documenting stop times.  The flip side to instructing the RNs to enter stop times is that they are entering them when they have time to document and not necessarily when the infusions and hydrations are completed.  I understand the time requirements for each and understand that if a hydration does not have a stop time, it is not billed and if an infusion does not have a stop time, it is billed as an IVP.  What do you do if an infusion and/or hydration has an invalid/inaccurate stop time?  Is the infusion downcoded to an IVP or not billed at all?  Sometimes they have a rate which makes it obvious that the stop time is invalid.  If the order specifies a time - say 1 hr - but the stop time is 2-3 hours later, is it still acceptable to charge more than 1 hr?


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## eadun2000 (Jul 2, 2011)

DelMarEs said:


> I work in very busy ER and we are struggling with RNs documenting stop times.  The flip side to instructing the RNs to enter stop times is that they are entering them when they have time to document and not necessarily when the infusions and hydrations are completed.  I understand the time requirements for each and understand that if a hydration does not have a stop time, it is not billed and if an infusion does not have a stop time, it is billed as an IVP.  What do you do if an infusion and/or hydration has an invalid/inaccurate stop time?  Is the infusion downcoded to an IVP or not billed at all?  Sometimes they have a rate which makes it obvious that the stop time is invalid.  If the order specifies a time - say 1 hr - but the stop time is 2-3 hours later, is it still acceptable to charge more than 1 hr?



As far as the order thing goes.. you do not code off of an order.. you code by what was actually done.


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