Q&A: Coding from NP documentation
Question: If a CDI specialist puts a sticker in the chart and a nurse practitioner (NP) signs it, can the coder code that diagnosis legally?
Answer: ICD-9-CM guidelines allow code assignment from a NPs documentation so it is important that you seek a compliant policy. I would suggest that you seek the NP scope of practice specific to your state. Although most states have similar scopes of practice, they can differ. I would suggest that you meet with your compliance department to create a facility specific policy regarding the NP scope of practice, and seek medical staff approval on the policy.
A sticker in the chart however is larger source of concern. It is not considered a valid part of a medical record and coding staff cannot report from something that is not part of the legal medical record. Additionally, signing your note as a method of agreement is not clinically valid data entry by a provider of medical care. There is not enough documented proof that the person did anything other than sign (without reading) the note, and that kind of “validation” would not be supportable as a clinical decision. A physician who signs the progress note of a medical student or nurse is not a substitute for the physician’s entry of the same verbiage in the medical record and will not stand under legal scrutiny.
(Robin Holmes and Robert Gold of the ACDIS advisory board answered this question)
About the Author: Brian Murphy, CPC, is director of the Association of Clinical Documentation Improvement Specialists (ACDIS). Brian is also an executive editor in the revenue cycle division of ACDIS’ parent company HCPro, Inc.
Don | Oct 7, 2009 | Reply
I would like to know if the ‘sticker’ is a Post-It note style, or if is one of the pre-formatted queries that some organizations are using (the sticker is placed on a paper progress note). There is a huge difference!! The post-it note is simply wrong!
Along with that, the format of any standardized query is key, ought to have compliance input, needs to have somewhere documentation supporting the relevance of the diagnosis to the current stay & course of treatment, etc.
I fully agree with Brain’s comments about there needing to be facility-specific policies regarding documentation by NPs, PAs as well as the utilization of an RN to assist the attending with documentation, etc.