In this blog series, we will feature tips & tricks from Galen resident MEDITECH expert and Principal Consultant, Kelly Del Gaudio.
Although CMS does not specifically require documentation of start and stop times, infusions are only reimbursable on a per-hour basis . Documentation of infusion start and stop time is imperative to justify the number of minutes (or hours) an infusion ran.
The physician order should document:
- Administration route
- Rate at which the drug is given.
The nursing documentation should include:
- Location of the injection/IV site
- Patient vital signs at initiation of the infusion
- Start time of each infusion
- Rate of each infusion
- Assessment of the line
- Stop time of each infusion
When a physician places an order into MEDITECH, it triggers a set of required elements that a clinician, whether it be a nurse or provider, is required to answer to initialize the infusion. Most of this information is documented on the MAR and can be as simple as scanning the bag. Recording the DC documentation however, can be somewhat cumbersome as there are no standard enforcing protocols in place. Without a solid workflow this leaves many infusions at risk of being inaccurately documented and ineligible for reimbursement.
In fact, most MEDITECH organizations are challenged in documenting accurate stop times which often leads to understated billings and coding audit risk. In the case of the latter, coders who don’t code the infusion with an accurate stop time may end up reporting an injection instead (an injection is defined as an infusion that lasts less than 15 minutes).
Within MEDITECH, a simple rules-customization can ensure accuracy of infusion stop time, calculate the total run time and drive measurable increase in revenue. View our MEDITECH IV Charge Capture Setup Guide to get started. Check out our other MEDITECH based blogs here.
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