Nurse practitioner coding practices in primary care: a retrospective chart review

Journal Name: 
J Am Acad Nurse Pract
Authors: 
Allen,K.R.
Reinke,C.B.
Pohl,J.M.
Martyn,K.K.
McIntosh,E.P.
Abstract: 
PURPOSE: To describe the coding and documentation practices of nurse practitioners (NPs) when using evaluation and management (E & M) codes in an academic primary care center. DATA SOURCES: A randomized retrospective review of ten charts from a nurse-managed primary care clinic affiliated with a midwestern research-intensive university. CONCLUSION: The findings demonstrate that the documentation in the chart for six of the ten client encounters did not support the E & M codes assigned by the clinicis NPs. Four of these six client encounters were overcoded; the remaining two encounters were undercoded. IMPLICATIONS FOR PRACTICE: Findings of this study support the need for additional education of NPs in the areas of coding and documentation
5
2003
Volume: 
15
Pages: 
231-236
Keywords: 
Documentation, education, evaluation, Forms and Records Control, Human, Michigan, MNCCRN, Nurse Practitioners, Nursing Records, Physician's Practice Patterns, primary care, Primary Health Care, Random Allocation, Retrospective Studies, review, statistics & numerical data, support, Universities