Mindy Davis
Networker
I know we can't use diagnosis from Triage and nurse's notes but does any you have any supporting information as to why we can't use documentation from the nurses for DX?
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Wiki Triage/Nurse's Notes
- Thread starter Mindy Davis
- Start date
GaPeach77
Guru
Unless it is a NP or some type of specialty nurse it is out of their scope of practice. That really isnt a coding guideline that is a clinical one. The coding guideline is not to use the nurse's note because of the clinical aspect of who can give a diagnosis.
Mindy Davis
Networker
Right but I'm looking for documenataion (from payers, coding updates, coding semiars) as to why we are not allowed to use nurse documentation. My director wants it in writting. Me simply saying it doesn't work. Thanks for your reply.
mitchellde
True Blue
Perhaps this might help?
In the coding guidelines it states:
Coding Guidelines, effective October 1, 2011:
The term encounter is used for all settings, including hospital admissions. In the context of these guidelines, the term provider is used throughout the guidelines to mean physician or any qualified health care practitioner who is legally accountable for establishing the patient’s diagnosis. Only this set of guidelines, approved by the Cooperating Parties, is official.
In the coding guidelines it states:
Coding Guidelines, effective October 1, 2011:
The term encounter is used for all settings, including hospital admissions. In the context of these guidelines, the term provider is used throughout the guidelines to mean physician or any qualified health care practitioner who is legally accountable for establishing the patient’s diagnosis. Only this set of guidelines, approved by the Cooperating Parties, is official.