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PubMed · 12800804

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

Kymberly R Allen·Caroline B Reinke·Joanne M Pohl·Kristy K Martyn·Elaine P McIntosh
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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.

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Forms and Records ControlHumansNurse PractitionersNursing RecordsPractice Patterns, Physicians'Primary Health CareRandom AllocationRetrospective StudiesJournal Article

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Kymberly R Allen, Caroline B Reinke, Joanne M Pohl, Kristy K Martyn, Elaine P McIntosh. 2003. Nurse practitioner coding practices in primary care: a retrospective chart review.. https://doi.org/10.1111/j.1745-7599.2003.tb00364.x

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