Wiki What are the Documentation Requirements for Viscosupplementation (Monovisc, Euflexxa, Durolane, etc)?

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KStaten

KStaten

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Hello Everyone,

I am searching for the documentation requirements for viscosupplementation injections, such as Monovisc and would appreciate if someone could point me in the right direction. As these are administered in pre-measured syringes, I have (on one hand) been advised that the dosage does not need to be included in the documentation within the note as long as the office has records of the orders with that information available. In this scenario, a statement such as "The Monovisc injection was administered today in the right/left knee," would be sufficient. However, on the other hand, I have also been advised that the note should not only include the dosage, as well, but also additional information, such as expiration date, lot number, etc. Granted, while erring on the side of caution (with documenting more information) seems to be the safest, most thorough choice, if it is not required (assuming the office has all of this information stored in orders/ records) this would "lessen the burden" in regards to documentation. I would appreciate any references to guidelines in regards to this, as well as any input / suggestions.

As always Thank You in Advance,
Kim
 
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Look at the practical side... your patient needs a surgeon, perhaps something that no one in your office does (or your patient moves to another state). You send the records. Does that surgeon know what you injected? Are you going to send your ordering records along with the patient's records? What if the referral is three years into the future and now Euflexxa comes in multiple strengths, how will that surgeon know what you did? I don't think that records are complete or accurate that rely on information stored elsewhere.
 
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SharonCollachi said:
Look at the practical side... your patient needs a surgeon, perhaps something that no one in your office does (or your patient moves to another state). You send the records. Does that surgeon know what you injected? Are you going to send your ordering records along with the patient's records? What if the referral is three years into the future and now Euflexxa comes in multiple strengths, how will that surgeon know what you did? I don't think that records are complete or accurate that rely on information stored elsewhere.
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Thank you, Sharon. :) That is a VERY good point. I agree, and, as a patient and a coder, I would prefer all reports to be as accurate and thorough as possible. However, I'm sure we have all encountered that in this field, physicians and clinical staff sometimes prefer less documentation so that they can spend more face-to-face time with their patients. (Hence, Medicare's attempts to lessen the burden of documentation.) But, as you have pointed out, the need for thoroughness in the reports isn't just for the practical/ legal use of the facility, it affects the continuation of care for the patient-- which should be the main focus for any healthcare facility. Thank you for your excellent input!
 
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I agree with both of you. And I don't think the excuse that too much documentation takes away from face-to-face time with patients is acceptable. I was always taught "If you don't record it, you didn't do it" so the action of treatment coincides with the action of recording it. You're protecting the patient and the yourself when you document so it's a win-win in my opinion. If coders are supposed to be specific, then drug, dose, and route should be the minimum documented on a claim. The lot numbers with expiration dates should be recorded and kept in the office. Actually, any time a med is given the provider should be checking the expiration date before drawing it up just as a habit of drug administration.
I don't believe this is an area Medicare is trying to modify.
 
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The doctor doesn't have to be the one to record the dosage, lot#, expiration date, etc., of a pre-filled syringe. The staff can do that when they get the supplies ready for the doctor. So I think the reason of it takes too long to document is bogus, because the staff can do it at any time.
 
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SharonCollachi said:
The doctor doesn't have to be the one to record the dosage, lot#, expiration date, etc., of a pre-filled syringe. The staff can do that when they get the supplies ready for the doctor. So I think the reason of it takes too long to document is bogus, because the staff can do it at any time.
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Exactly. ;)
 
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fwnewbie said:
I agree with both of you. And I don't think the excuse that too much documentation takes away from face-to-face time with patients is acceptable. I was always taught "If you don't record it, you didn't do it" so the action of treatment coincides with the action of recording it. You're protecting the patient and the yourself when you document so it's a win-win in my opinion. If coders are supposed to be specific, then drug, dose, and route should be the minimum documented on a claim. The lot numbers with expiration dates should be recorded and kept in the office. Actually, any time a med is given the provider should be checking the expiration date before drawing it up just as a habit of drug administration.
I don't believe this is an area Medicare is trying to modify.
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Agreed. ;) And, no this is not an area that Medicare is attempting to modify. I apologize for the confusion, as I was referring to their other attempts, such as allowing ancillary staff to document the HPI. I think that we, as coders, definitely agree that more documentation is better. Clinical staff do not always share the same mindset, so it is always nice to have the support of shared perspectives from my coding community. Thank you. :)
 
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I totally agree coding is much easier/accurate with as much info as possible.
I'm also a nurse can can't imaging clinical staff not wanting to chart completely. Maybe they've never been deposed and had to explain their charting! That'll make a believer out of ya!!
 
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