AHA Coding Clinic® for HCPCS - 2013 Quarter 1; ASK the EDITOR
Reporting of procedure without physician documentation
A hospital-employed nurse or technician may perform a procedure in an emergency department or clinic that was ordered by a physician, examples of these services include, but are not limited to, drug infusions, foley catheter insertions, strapping and splint applications. Can the hospital code for the procedure without the note from the physician describing the procedure? ...
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Article Overview
This article discusses facility procedure coding when a service is performed and documented by a nurse or technician rather than by the ordering physician. It focuses on when documentation from the individual who actually provided the service may support coding, and clarifies the general scope of that guidance. The topic is relevant to hospital coders, CDI staff, and billing personnel working with emergency department and clinic records.
Why This Topic Matters
Hospitals often rely on documentation created by the clinician who performed a service, not only on physician notes. Understanding the scope of this guidance helps coding teams evaluate record support for facility procedure reporting.
What You Will Learn
- When documentation from the person who performed a facility procedure may support reporting
- How the guidance applies in a hospital emergency department or clinic setting
- The general scope limits of the advice for procedure coding
- The difference between procedure coding guidance and diagnosis coding guidance
Who Should Read This
- Hospital coders
- Emergency department coding staff
- Clinic billing staff
- Clinical documentation integrity professionals
- Revenue cycle personnel
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