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Documentation Tip of the Week: To Cover

Posted on Wed, Oct 28, 2015
Documentation Tip of the Week: To Cover

Our weekly feature of documentation tips for clinicians.

By Timothy Brundage, MD

DID YOU KNOW?

Documenting “To Cover” for gram negative rods does NOT code to gram negative Pneumonia.

DO NOT document: Pneumonia- will Rx Zosyn “To Cover” for gram negative rods.

CONSIDER INSTEAD: “Possible” gram negative rod Pneumonia- will Rx Zosyn.

The term “To Cover” does not code to the diagnosis. However, documenting a “POSSIBLE” diagnosis is acceptable language in the hospital setting.



Dr. Timothy Brundage is a hospitalist for EmCare at St. Petersburg General Hospital in St. Petersburg, Fla. Dr. Brundage earned his bachelor’s degree in chemistry and molecular biology at the University of Michigan, his M.D. at the Wayne State University School of Medicine and completed his residency in internal medicine at the University of South Florida College of Medicine. Subscribe to Dr. Brundage’s weekly documentation tips, or ask him about specific documentation issues, by emailing him at DrBrundage@gmail.com.

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