One of the most vexing issues coding professionals face when coding for infusions and drug administration is the absence of start and stop times.
According to the Centers for Medicare & Medicaid Services (CMS) Transmittal 902, hospitals are to report codes that indicate the actual time in which an infusion is administered to a beneficiary. If the start and stop times are not recorded, which unfortunately happens more often than we desire, then the coder is often forced to code an IV push.
The financial impact of this default code may be significant, especially in organizations that specialize in high-cost, chemotherapy-related anti-neoplastic infusions.
We have clients who have calculated their losses in the millions per year. When nurses are asked to be more diligent with recording their times, excuses that often surface include “we were busy caring for another patient and don’t know the exact time the infusion stopped” or “we are here to care for the patient, and our documentation focuses on the care we delivered.”
In addition to the medication record or nursing notes reflecting the start and stop times, there are some other acceptable documentation approaches allowed, according to Medicare’s Part A’s Job Aids & Manuals – Coding for Drugs and Biologicals, including:
- Record/notes indicating length of infusion after the infusion is completed;
- Record/notes indicating rate of infusion and quantity infused after the infusion is completed;
- Record/notes indicating pump times/settings and amounts infused after the infusion is completed; and
- Record/notes that enable a reviewer to accurately determine the length of time an infusion ran after the completion of the infusion.
However, these alternatives are often targets when external auditors review encounters, since they will focus their attention on how the infusion actually ran – not how it was supposed to run.
Health information management (HIM) professionals need to advocate for capturing the start and stop times. To successfully achieve the documentation required, organizations should at least consider three options:
According to Jane Werner, vice president of First Class Solutions, the first option is that hospitals bite the bullet and hire infusion nurses. They start all infusions and document the start and stop times. Considering the money the hospitals are losing, they can afford infusion nurses, and they should pay them more than the regular nurses.
The second option is to purchase infusion pumps that electronically populate the documentation and time in your electronic health record (EHR). They are pricey, but again, it is a drop in the bucket when a facility is losing millions. The important thing here is to make sure that the pump technology fully integrates with your EHR.
Finally, I suggest that we assess a unique use of scribes that may be beneficial in this situation. Just as a scribe supports physician documentation efforts, couldn’t we use a scribe to support nursing documentation efforts? We know that scribes cannot be licensed independent practitioners, so that eliminates the use of PAs or NPs, but it opens opportunities for nursing students, medical students, HIM professionals, and others.
The entries need to be made while both the scribe and nurse are present with the patient. Scribes cannot administer medication; however, I have not found anything in the literature that limits them from monitoring medication. Therefore, the scribe’s attention will need to be on the infusion’s start and stop times, and the nurse’s attention will be on the patient and any symptoms they are exhibiting.
When the nurse starts the infusion, he or she need only state that the infusion is starting for the scribe to capture the time. When the infusion stops, the scribe can bring it to the attention of the nurse in order to ensure that the time is definitively established before the scribe records it.
Is there a catch? Yes! However, that is where your legal counsel needs to get involved to assess CMS and Medicare Administrative Contractor (MAC) policies related to scribes. Hospital associations should advocate on behalf of their members as well with CMS and their regional MAC. This means that we will need CMS or the MAC to accept scribe entries – specifically, we need to know: can the scribe enter the start and stop times? If so, do they need to be privileged to do so by the medical staff?
When physicians use scribes, the physician must review and sign off on the documentation created by them. This implies that the nurse attending the patient would be required to review the documentation for accuracy and sign off on the scribe’s start and stop times. If the standard operating procedure provides for nursing confirmation with documentation support from the scribe, the use of scribes may be the solution to a major coding and financial challenge.