# Nursing Documentation Requirements



## Beth Neitz (Jan 6, 2010)

I am in need of nursing documentation requirements for infusions.  Our ED nurses are refusing to document start and stop times and I need information to review with them. thanks.


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## Eena (Jan 8, 2010)

I also need this as we begin battle with our nurses over their documentation.  Already, nursing administration is crying about the impact this is going to have on their staff if they have to document start and stop times.  I need something to prove to them that this is required.


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## jleonard8501 (Jan 21, 2010)

We can not charge for infusions if there is no start and stop time.......there is a site that i will find and post that has the rules for documentation


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## LTibbetts (Jan 25, 2010)

I am definitely no expert in this area but I know for sure that there is an abundance of information regarding this as you can't properly code infusions/injections _without_ the start/stop time if you want to be fully imbursed. The codes themselves are defined by the amount of time spent (ie initial, up to 1st hour, each additional hour, etc). For starters, have them read the CPT coding book (on page 487 for 2010 version). This clearly states the coding guidelines for these procedure codes. Also you may want to reiterate to them that, as coders, we can not code what is not documented so if it is not there, then the hospital/clinic is not going to get paid for it. If you still can't win with them, I'm sure that if you go to administration, surely they will understand the importance of this. Below is also a website that has some helpful hints about coding for these.

http://www.irminconline.com/documen...008 - Hydration, Injections and Infusions.pdf

I hope this helps you out


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## mitchellde (Jan 25, 2010)

Eena said:


> I also need this as we begin battle with our nurses over their documentation.  Already, nursing administration is crying about the impact this is going to have on their staff if they have to document start and stop times.  I need something to prove to them that this is required.



I ran into this as well and what I fail to understand is the nursing schools teach this as a part of their nursing curriculum.  So I would say do what I did and go to the nursing school nearest to you and ask for a copy of the instructions on documentation of IVs.  It was a good feeling to hand that over to the nursing supervisor.


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## LTibbetts (Jan 26, 2010)

Touche, Deb, Good for you! I would have loved to see their faces.....What a brilliant idea!


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## ptrautner (Jan 29, 2010)

you just have to remember if it is a time based code and there is no stop time you cannot bill it and if you count how many are not documented over the course of a year and dollars that are left on the table..they may see the importance of the documentation.


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## Rita Bartholomew (Feb 5, 2010)

I agree with showing them the financial losses attributable to uncoded infusions.  In this economy, you shouldn't be leaving so much money on the table.  The nurses should understand that there really is no choice in the matter.


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## kjohnson (Feb 5, 2010)

I approached our ER nursing supervisor and explained we were potentially losing hundreds if dollars a day of lost revenue if the nursing staff does not document start/stop times. It worked! Our nurses do an awesome job at it now!! Money talks


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## SFowler150 (Jan 4, 2012)

mitchellde said:


> I ran into this as well and what I fail to understand is the nursing schools teach this as a part of their nursing curriculum.  So I would say do what I did and go to the nursing school nearest to you and ask for a copy of the instructions on documentation of IVs.  It was a good feeling to hand that over to the nursing supervisor.


I can answer this question because I am a nurse and the answer is no. The standard of practice is to document the drug/dosage/route, etc.given and the time it was hung. Not documenting the stop time is a billing issue and has nothing to do with patient care. Educating the nursing staff about missed revenue opportunities by not documenting the stop time will go a lot further than trying to one over them, especially when they are within their standard of practice. Sorry to be so "snippy", but I don't like to see these types of posts about nursing.


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## mitchellde (Jan 4, 2012)

I hate to disagree but it cannot be a billing issue with out it being a documentation issue first.  And was in the nursing school curriculum that both start and stop times were to be documented by the nurse.  If they do not do it then who?  The biller cannot bill without it.  And it is a patient care issue since it is necessary to know how long an infusion has been going for good patient care.  So I respectfully disagree with you.


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## kcampbell (Jan 20, 2015)

*Infusion coding*

I was always thought that if the stop time wasn't documented we couldn't code for the service. I have seen facilites down code the service to a IV Push 96374 instead of an infusion if there is no stop time. Do you agree with this practice?


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