Nurse practitioner coding practices in primary care: a retrospective chart review.
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.
Allen
Kymberly R
KR
Nurse Managed Centers, University of Michigan School of Nursing, Ann Arbor, MI, USA. kymallen@yahoo.com
Reinke
Caroline B
CB
Pohl
Joanne M
JM
Martyn
Kristy K
KK
McIntosh
Elaine P
EP
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