Related Experiment Videos
Nurse practitioner coding practices in primary care: a retrospective chart review
Kymberly R Allen1, Caroline B Reinke, Joanne M Pohl
1Nurse Managed Centers, University of Michigan School of Nursing, Ann Arbor, MI, USA. kymallen@yahoo.com
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.