Question:
What documentation should be reviewed before determining drug administration codes for an observation encounter?
Answer:
The following should be considered before determining the drug administration codes for any observation encounter:
- Missing start and stop times. Remember for any infusions, including hydration, the stop time needs to be documented in order to support this coding. If the hospital has a policy for intravenous pushes or therapeutic infusions that are missing stop time, staff will need to follow the hospital’s own internal policies. Be aware of your Medicare MAC (and other payer) guidance where applicable.
- Missing stop time in the MAR. Go to the nursing documentation to determine if a stop time was documented elsewhere. Query nursing staff if documentation is not found. It is not advisable to ask nursing to add a late entry for stop time in the nursing documentation so that a code may be reported. Remember you must follow your internal health information management (HIM) policies for any late entries in the medical record.
