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

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.