coding from nursing documentation

afeighnerafeighner
in CDI Talk Archive
Hello

Some of the coders I am working with are dual coding in ICD-9 and ICD-10 and are having questions about coding from nursing documentation when provider documentation may elude to / and or connect to something in nursing documentation. Is there a resource anyone can share that addresses this? Thank you in advance.

Comments

  • catladyrncatladyrn
    I don't have a specific reference but AFAIK, there's no difference in ICD-10 as to what we are allowed to take from nursing documentation. Physicians may allude to nursing documentation, and it's great when nursing and physician documentation are consistent, but the docs are still the ones who have to document to the specificity required. They can't just write, "see nurse's note," and be able to have that reported, with, of course, the usual exceptions for BMI and pressure ulcer stage. You could look at developing templated documentation processes in the EMR that pull nursing assessments into the choices physicians can use when building their notes, which would allow them to use what nursing has written. But other than that, they're still on the hook for capturing all reportable diagnoses.

    However, none of this may be what you're asking...

    Renee

    Linda Renee Brown, RN, MA, CCDS, CCS, CDIP
    Director, Clinical Documentation
    Tanner Health System
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