Wiki Coding from Nursing documentation

[SBAMH3300]

Can someone provide me where to find documentation stating that when coding hospital charts that we cannot use the nursing documentation to code from? Our CDI using nursing notes but it is not always in the physician documentation. From what I have been reading it appears we can only code from a physician, Pa's, APRN as they are responsible for determining what care is needed and a plan for the care.

Thank you,

Amy

 

[Pam Warren]

You cannot use nurse notes to directly assign a diagnosis code. However, nursing notes that include clinical indicators can be used by CDI nurses to potentially query a physician for clarification of a condition and potentially a different diagnosis code that would abstract to a higher DRG or HCC.

 

[SBAMH3300]

Thank you. is there anywhere we can find that in writing? I am reading the reason coders cannot use nursing documentation is because they are not deciding the care of the patient, etc. is this correct?

 

[Pam Warren]

ICD-10-CM Instructional Notes: Documentation by Clinicians Other than the Patient's Provider

Code assignment is based on the documentation by patient's provider (i.e., physician or other qualified healthcare practitioner legally accountable for establishing the patient's diagnosis).
There are a few exceptions, such as codes for the Body Mass Index (BMI), depth of non-pressure chronic ulcers, pressure ulcer stage, coma scale, and NIH stroke scale (NIHSS) codes, code assignment may be based on medical record documentation from clinicians who are not the patient’s provider (i.e., physician or other qualified healthcare practitioner legally accountable for establishing the patient’s diagnosis), since this information is typically documented by other clinicians involved in the care of the patient (e.g., a dietitian often documents the BMI, a nurse often documents the pressure ulcer stages, and an emergency medical technician often documents the coma scale). However, the associated diagnosis (such as overweight, obesity, acute stroke, or pressure ulcer) must be documented by the patient’s provider. If there is conflicting medical record documentation, either from the same clinician or different clinicians, the patient’s attending provider should be queried for clarification.

ACDIS and AHIMA both have a lot of information with regards to the role of the CDI nurse and abstraction of clinical documentation for query purposes.

Additionally, check your state Nurse Scope of Practice....nurses are not allowed to assign a medical diagnosis. Here's the language in Maine:
Maine Revised Statutes
TITLE 32: PROFESSIONS AND OCCUPATIONS
Chapter 31: NURSES AND NURSING
Subchapter 1: GENERAL PROVISIONS
32 §2102. Definitions

Professional Nursing, "Diagnosis" in the context of nursing practice means that identification of and discrimination between physical and psychosocial signs and symptoms essential to effective execution and management of the nursing regimen. This diagnostic privilege is distinct from medical diagnosis;