In this issue:

• Coding News
  • LYNX new Patient Management & Clinical Documentation System at Swedish Medical Center EDs is unveiled at HIMSS in Dallas
• Compliance Corner
  • Documenting Parenternal Medications and IV Infusions

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Coding News

LYNX new Patient Management & Clinical Documentation System at Swedish Medical Center EDs is unveiled at HIMSS in Dallas

Candace E. Shaeffer, RN, MBA, RHIA
Vice President, Coding Operations/Quality Management

Participants at the annual Health Information and Management Systems Society (HIMSS) conference and exhibition responded enthusiastically to the new LYNX patient management and clinical documentation system to be deployed at Swedish Medical Center (SMC). SMC, a long-time LYNX client, engaged LYNX Medical Systems to work with Motion Computing and Microsoft in the development and implementation of an Emergency Department (ED) patient management and clinical documentation solution. The goal was to increase throughput and efficiency in Swedish’s four disparate EDs.

Employing Microsoft Office 2003’s InfoPath technology, LYNX developers created an on-line patient management and clinical documentation tool that will allow the SMC ED nurses and social workers to document the triage, assessment and other care they provide for their ED patients. Documentation will be entered into the user friendly forms via a Motion Computing wireless tablet. In compliance with HIPAA security rules, logging in will be simple and an audit trail will be created using the Motion biometric thumbprint recognition imbedded in the computer tablet.  Likewise, clinical documentation using the LYNX forms will be easily accomplished through a series of check boxes, drop down boxes or free text entries using a keypad or digital stylus.

Swedish administrators and caregivers had several goals in mind at the outset of this project. They wanted to streamline workflows, enhance documentation quality, reduce wait times, increase accessibility to patient online information, increase patient safety and increase billing accuracy. These quality improvement measures will be realized using:

• the electronic forms to document clinical care
• an ED orders form that will allow easy entry and viewing of orders by multiple caregivers
• clinical views of patient data that will show a caregiver all of his or her assigned patients and a task list associated with those patients in real-time
• an electronic ED whiteboard to track patients, their caregivers, orders and the status of those orders—new, in process or completed, and manage bed availability.

This new system for documentation and ED workflow management will also provide several benefits to Swedish’s revenue cycle management process. An ADT registration interface will pre-populate the LYNX ED log and electronic forms with patient information, eliminating the need for caregivers to manually enter information. This will increase the accuracy of the information as well as the efficiency of the clinical process. The standardized, structured documentation will enhance the capture of clinical information and improve the back-end coding and billing processes. This new LYNX patient management and clinical documentation system is scheduled to be in use at Swedish in May 2005.

Compliance Corner

Documenting Parenternal Medications and IV Infusions

By Ann Florer, RN, CCS-P
Coding Compliance Manager

Two of the most frequently assigned nursing procedures which significantly impact ED reimbursement are medications administered via a parenteral route such as intramuscular (IM), intravenous (IV) or subcutaneous (SC) and the administration of fluids and/or medication via an IV infusion. In order to assign the correct code(s) for these procedures, specific nursing documentation elements are required:

• the route of administration
• stop and start times for infusion (including secondary infusions)
• whether medications were combined for a single injection or given separately (e.g., Demerol/Phenergan).

Definitions

IV Push (IVP) implies a medication administration that is completed before the caregiver leaves the bedside. These are typically in a syringe, require minimal, if any dilution and are given at a rapid rate; for example, a five-minute push of a narcotic or a 10-second push of an anti-emetic.

Infusion or IV piggyback (PB) includes any medication that needs to be administered over a “timed” interval or as an “infusion.” These are typically in a bag, bottle or large-volume syringe and placed on a pump or infused by gravity. They would require additional IV tubing to hook to the IV site or maintenance fluid line.

Because IV medications can be given via either an infusion or injection, it is important to avoid documenting only the term “IV.” If a medication is added to an existing IV infusion, indicate this as well (e.g., 20meq KCl added to 900 cc remaining of IV infusion) and for good clinical documentation, nurses should also note the infusion rate. Examples of good documentation include:

• For an Infusion: Nitroglycerin drip 5mcg/hr or Flagyl ® 500mg/100cc NS IVPB
• For an Injection: Morphine 2mg IVP or Rocephin ® 250mg/10cc NS slow IVP.

Documenting for IV Infusions

The Center for Medicare and Medicaid Services (CMS) provides rules and guidance for correct coding and revenue capture. CMS states that in order to code for an IV infusion, the infusion must be given for therapeutic or diagnostic reasons. Examples include hydration therapy in a hypertensive patient or an antibiotic infusion in a septic patient.

Coding for IV infusions is especially problematic, because often two separate codes must be reported. The first code, 90780, is to report an IV infusion, which runs up to one hour. For every additional hour the IV runs, a second code, 90781, is reported with the number of hours the infusion ran. In addition, IV infusions may not be coded when the sole purpose of the fluid administration is to maintain the patency of the access device or if the infusion is ordered on a “routine” basis, “per protocol” or for prophylaxis, according to “standing orders” or “KVO,” etc. Additional documentation hints to ensure accurate infusion and injection coding include:

• Always document the rate on an IV infusion including TKO, KVO or per gravity
• Document stop, as well as start-times for IV infusions
• When an IV infusion is ordered as a “bolus,” indicate for how long the bolus ran (e.g., 500 cc bolus over 20 minutes or IV decreased at 2100 to 100cc/hr after 500cc bolus).