title: Nurse practitioner coding practices in primary care: a retrospective chart review.
abstract: OBJECTIVE
  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.
  
  
  METHODS
  A randomized retrospective review of ten charts from a nurse-managed primary care clinic affiliated with a midwestern research-intensive university.
  
  
  CONCLUSIONS
  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.
  
  
  CONCLUSIONS
  Findings of this study support the need for additional education of NPs in the areas of coding and documentation.
authors.affiliation: Nurse Managed Centers, University of Michigan School of Nursing, Ann Arbor, MI, USA. kymallen@yahoo.com
authors.forename: Kymberly R
authors.initials: KR
authors.lastname: Allen
authors.forename: Caroline B
authors.initials: CB
authors.lastname: Reinke
authors.forename: Joanne M
authors.initials: JM
authors.lastname: Pohl
authors.forename: Kristy K
authors.initials: KK
authors.lastname: Martyn
authors.forename: Elaine P
authors.initials: EP
authors.lastname: McIntosh
mesh_terms: D005568:Forms and Records Control / Q000706:statistics & numerical data*; D006801:Humans; D009722:Nurse Practitioners / Q000706:statistics & numerical data*; D009737:Nursing Records / Q000706:statistics & numerical data*; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011320:Primary Health Care / Q000706:statistics & numerical data*; D011897:Random Allocation; D012189:Retrospective Studies