RE: [EXTERNAL] re:coding from nursing documentation
Thanks Renee! Great idea! I will be looking at the templates with CIS as suggested to see if our providers can indeed pull in additional things like GCS scores from the nurses notes and then will share with nursing how their documentation helps support the providers diagnoses.
I also wanted to share that one of the things coders always want more specific physician documentation on is the external cause codes and this Coding Clinic is great to share both with coders and the nurses.
Sorry if anyone else already shared this:
Coding Clinic, First Quarter ICD-10 2014 Page: 19 Effective with discharges: March 31, 2014
Question:
External causes of morbidity coding may require up to four codes to identify the cause of injury, the intent of the injury (accident versus intentional), the place of injury, and the person’s status at the time of injury. Can you please clarify whether coders must use physician documentation or if coders can use information from non-provider documentation, such as nurse’s notes, documentation from ambulance transport, etcetera? It seems that it would be labor intensive to expect a physician to restate documentation that may have already been provided by ambulance transport or the emergency room nurse. Would you please address this issue nationally so everyone can be consistent?
Answer:
Coders should use information contained in the official medical record. Codes for external causes of morbidity are assigned based on physician documentation; however, if the physician does not document external cause information, coders may use documentation available from nonphysicians. If there is conflict between the physician and nonphysician documentation, the physician’s documentation takes precedence.
Tina
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, July 22, 2015 11:25 AM
To: Brooks,Tina
Subject: RE: [EXTERNAL] re:[cdi_talk] coding from nursing documentation
I think Renee is correct. I would also reference any applicable ICD-10 Coding Clinics which are now out there. I haven't reviewed them myself, but I suspect many things will not change.
Robert
Robert S. Hodges MSN, BSN, RN, CCDS, VHA-CM
Clinical Documentation Improvement Specialist
Secretary, Nursing Professional Standards Board
Aleda E. Lutz VA Medical Center
1500 Weiss Street, ATTN PAS-136
Saginaw MI 48602
989-497-2500 x13101
Robert.Hodges2@va.gov
VA Core Values: Integrity, Commitment, Advocacy, Respect, Excellence (“I CARE”)
VA Core Characteristics: Trustworthy, Accessible, Quality, Innovative, Agile, Integrated
"The difference between the right word and the almost right word is the difference between lightning and the lightning bug." Samuel "Mark Twain" Clemens
I also wanted to share that one of the things coders always want more specific physician documentation on is the external cause codes and this Coding Clinic is great to share both with coders and the nurses.
Sorry if anyone else already shared this:
Coding Clinic, First Quarter ICD-10 2014 Page: 19 Effective with discharges: March 31, 2014
Question:
External causes of morbidity coding may require up to four codes to identify the cause of injury, the intent of the injury (accident versus intentional), the place of injury, and the person’s status at the time of injury. Can you please clarify whether coders must use physician documentation or if coders can use information from non-provider documentation, such as nurse’s notes, documentation from ambulance transport, etcetera? It seems that it would be labor intensive to expect a physician to restate documentation that may have already been provided by ambulance transport or the emergency room nurse. Would you please address this issue nationally so everyone can be consistent?
Answer:
Coders should use information contained in the official medical record. Codes for external causes of morbidity are assigned based on physician documentation; however, if the physician does not document external cause information, coders may use documentation available from nonphysicians. If there is conflict between the physician and nonphysician documentation, the physician’s documentation takes precedence.
Tina
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, July 22, 2015 11:25 AM
To: Brooks,Tina
Subject: RE: [EXTERNAL] re:[cdi_talk] coding from nursing documentation
I think Renee is correct. I would also reference any applicable ICD-10 Coding Clinics which are now out there. I haven't reviewed them myself, but I suspect many things will not change.
Robert
Robert S. Hodges MSN, BSN, RN, CCDS, VHA-CM
Clinical Documentation Improvement Specialist
Secretary, Nursing Professional Standards Board
Aleda E. Lutz VA Medical Center
1500 Weiss Street, ATTN PAS-136
Saginaw MI 48602
989-497-2500 x13101
Robert.Hodges2@va.gov
VA Core Values: Integrity, Commitment, Advocacy, Respect, Excellence (“I CARE”)
VA Core Characteristics: Trustworthy, Accessible, Quality, Innovative, Agile, Integrated
"The difference between the right word and the almost right word is the difference between lightning and the lightning bug." Samuel "Mark Twain" Clemens