JustCoding's Drug Administration Capture and Audit Tool
Valerie A. Rinkle, MPA
JustCoding's Drug Administration Capture and Audit Tool provides multiple critical tools for nurses, providers, and drug administration staff. It includes an easy-to-follow pocket card reference that will help coding staff report the most accurate CPT codes per the drug administration hierarchy. The back of the pocket card includes a list of nursing interventions and procedures that are separately identifiable. Having this information immediately available will let coders and billers quickly determine when to count these interventions as separate procedures.
In addition to the pocket card, this resource includes an electronic downloadable component that will allow providers to set up an IV medical administration record (MAR) within an EMR. Staff will be able to quickly and efficiently pull medications from the discharge MAR with start and stop times, as well as the route of administration. This tool will allow billing or auditing staff to instantly generate reports when looking for justification for administering and charging a certain drug (e.g., chemotherapy). The download includes an Excel workbook that details a work plan for implementing the tool, along with sample logic, reports, and easy-to-understand instructions.
From distributable pocket cards that will help guide clinicians and coders to an auditing tool that can be used to confirm accuracy, JustCoding’s Drug Administration Capture and Audit Tool provides comprehensive resources that will help ensure accurate charge capture.
- A convenient pocket card, allowing coders, billers, and nurses to track drug administration services and properly report them on the go or at their desks.
- An IV MAR, to help enable effective and efficient auditing of drug administration services.
- A handy list of separately reportable nursing services, giving coders and billers a quick reference for knowing what to report in addition to drug administration.
- The only custom drug administration report tool on the market!
Pocket card includes:
- Hierarchy to follow for chemotherapy and non-chemotherapy drug administration
- Ability to identify whether a service is an infusion, push, or hydration
- Tracking for length of service
- Definitions of nursing interventions and procedures
Download component: This Excel file includes instructions for setting up a plan for generating drug administration information from a discharge MAR, as well as sample logic and reports
About the Author
Valerie A. Rinkle, MPA, is a lead regulatory specialist and instructor for HCPro's Revenue Integrity and Chargemaster Boot Camp®, as well as an instructor for HCPro’s Medicare Boot Camp®—Hospital Version and Medicare Boot Camp®—Utilization Review Version. Rinkle is a former hospital revenue cycle director and has over 30 years in the healthcare industry, including over 12 years of consulting experience in which she has spoken and advised on effective operational solutions for compliance with Medicare coverage, payment, and coding regulations.
Frequently Asked Questions
This tool contains a work plan for the project team, a sample of a drug master in the pharmacy system with different drugs categorized by drug administration category, a definition of drug administration categories, sample logic for the custom report, and a couple of report examples.
Why embark on a project to develop a custom drug administration medication record report?
A custom report will simplify and streamline the capture of drug administration services in emergency departments, in clinics, and for outpatients receiving observation services.
If you already capture drug administration services, why is a report necessary?
Whenever staff currently capture drug administration charges, they spend a lot of time sorting through the entire medication administration record. A custom report, designed to focus exclusively on infused and injected medications and organized per the charge capture and CPT coding rules, will significantly reduce this expenditure for each case.
If you do not currently capture drug administration charges, why design this report?
This report will enable effective charge capture in less staff time, which will increase net revenue to the organization.
What does the report do?
The custom report will exclusively display infused/injected drugs, organized by the drug administration hierarchy, in a simple format, making it very straightforward for staff to capture charges.
What is the outcome that should be expected if this report is created?
The report will significantly reduce time to capture and validate drug administration charges.
What is the expected return on investment to developing this custom report?
To calculate approximate return on investment, estimate the number of hours staff currently spend capturing drug administration services, estimate the annual expense of this charge capture, and then estimate the savings realized with a conservative 75% reduction in staff time spent.
A project to produce this report will take 2–3 months from inception, assuming the project team is also working on other concurrent projects.