Wiki Concurrent Infusion - same/separate bag

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lillianivy

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I need help.
2 or more drugs given in same bag or separate bag. In our EMR for the MAR where the drugs are documented it has start and stop times, dose amount, waste, unit, route, fluid, volume. When 2 or more drugs are given simultaneously they will have the same start and stop times. The nurses do not document rather they were given in the same bag or separate bag. They claim I am to figure it out by the fluid and volume documented. My dilemma is that there are occasions where the fluid and volume where the same when 2 or more drugs were given concurrently in separate bags. So it looks like they were given in same bag per documentation, but actually give in separate bags. We have come across this issue when we have had a claim audited. Since this can occur I have suggested the nurses take the extra step to document if the drugs are in separate or same bags. Well, I have received some backlash. As a coder I want to follow all rules and have clear documentation. I understand the nurses feel that documenting the fluid and volume is sufficient enough. So my question is.... Is that sufficient documentation, the fluid and volume, or does it need to clearly state same or separate bags?
I just don't want to give insurance any wiggle room to recoup money when audited.
 
The nurse must document all of this. The must state if a second bag is connected via a y connector for the concurrent infusion. Without this documented we must assume that any additional drugs documented are just additives in the same bag. If you check with your nested nursing school instructor or state board of nursing, they should verify this.
 
Thank you. Unfortunately when I took your statement to my supervisor, it was "not good enough". I do not feel comfortable coding unclear documentation. Especially since my name will be attached. I feel stuck. I love my job and I love where I work, but if I start letting things "slide" then I am afraid that puts me in jeopardy with following the strict rules and guidelines and makes me a poor coder. They are wanting something in writing. I have searched the web and reread the cpt guidelines. I am not a nurse and don't know who to contact regarding clinical documentation regarding this issue. Please help.
 
:confused:
lillianivy said:
Thank you. Unfortunately when I took your statement to my supervisor, it was "not good enough". I do not feel comfortable coding unclear documentation. Especially since my name will be attached. I feel stuck. I love my job and I love where I work, but if I start letting things "slide" then I am afraid that puts me in jeopardy with following the strict rules and guidelines and makes me a poor coder. They are wanting something in writing. I have searched the web and reread the cpt guidelines. I am not a nurse and don't know who to contact regarding clinical documentation regarding this issue. Please help.
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I'm not sure if this will help, as I'm sure it isn't as specific as your supervisor wants, but this information is from a RAC site. Look under Infusion Services "Most Frequent Documentation Problems",3rd bullet. It's a long shot, but that may be enough for the supervisor to realize that current documentation protocol isn't sufficient for Medicare RAC auditors.

:confused:


http://racmonitor.com/rac-enews/770...ecise-documentation-for-infusion-therapy.html
 
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