Q&A: Coding procedures from other providers’ documentation

Q: Can wound debridement performed by wound care nurses and/or physical therapist be reported on inpatient claims?

A: Absolutely. ICD-10-PCS codes can be assigned based on other providers’ procedure notes. I would suggest you make sure they are credentialed within your facility to perform these procedures, however.

AHA Coding Clinic, First Quarter, 2014, states that it’s appropriate to assign a procedure code based on documentation by a non-physician professional when that professional provides the service. This may be the only evidence that the service was provided.

Coding Clinic gives a few examples of situations when you can use other providers’ documentation for procedure coding:

• Infusions carried out by a nurse
• Mechanical ventilation provided by a respiratory therapist
• A drug ordered by the physician and administered by a nurse.

Note that this guidance only applies to the procedure, not the diagnosis. The treating physician still has to document the corresponding diagnosis for the treatment.

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, CRC, CDI education director at HCPro in Middleton, Massachusetts, answered this question on the ACDIS Forum. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps visit www.hcprobootcamps.com/courses/10040/overview.