Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
Appendix B Medicare Program, The Joint Commission, and International Classification of Diseases, Tenth Revision, Clinical Documentation and Coding Requirements Clinical Documentation and Coding Regulatory, Accreditation, and Requirements Coding Citations Brief Description Medical Record 42 CFR Â§ 482.24(c), Condition â¢ Content of record. Services- of participation: Medical record Documentation services Medical Record 42 CFR Â§ 482.24(c)(3)(i), â¢ Orders reviewed and ap- Services-Orders Condition of participation: proved by medical staff Medical record services and nursing and pharmacy 42 CFR Â§ 482.24(c)(3)(ii), leadership. Condition of participation: â¢ Orders are consistent with Medical record services nationally recognized and 42 CFR Â§ 482.24(c)(3)(iii), evidence-based guidelines. Condition of participation: â¢ Orders are dated, timed, Medical record services and authenticated promptly. 309
310 TAKING ACTION AGAINST CLINICIAN BURNOUT Clinical Documentation and Coding Regulatory, Accreditation, and Requirements Coding Citations Brief Description Medical Record 42 CFR Â§ 482.24(c)(4)(i)(A), â¢ Medical history and physical Services-History Condition of participation: examination. and Physical Medical record services â¢ Updated changes to history 42 CFR Â§ 482.24(c)(4)(i)(B), and physical within 30 days. Condition of participation: â¢ Admitting diagnosis. Medical record services â¢ Consultative evaluations and clinical findings. â¢ Documentation of complications, unfavorable reactions to drugs and anesthesia, and hospital- acquired infections. â¢ Documentation of properly executed consent forms. â¢ Documentation necessary to monitor patientâs condition, including orders, nursing notes, treatment reports, medication records, radiol- ogy and laboratory reports, and vital signs. Medical Record 42 CFR Â§ 482.24(c)(4)(vii) and â¢ Documentation of discharge Services- (viii), Condition of participation: summary, hospitalization Discharge Medical record services outcome, case disposition, Summary and provisions for follow-up care. â¢ Documentation of a final diagnosis with completion of the medical record within 30 days. Medical Record 42 CFR Â§ 482.43(c)(6)(iii) â¢ Documentation of a list of Services- Condition of participation: home health aides or skilled Discharge Discharge planning nursing facilities that are Planning available, participating in Medicare Program and serves the geographic area in which patient resides or requests, and that the list was presented to the patient or authorized individual.
APPENDIX B 311 Clinical Documentation and Coding Regulatory, Accreditation, and Requirements Coding Citations Brief Description Surgical Services 42 CFR Â§ 482.51(1)(i) Condition â¢ Medical history and physical of participation: Surgical services exam must be completed 42 CFR Â§ 482.51(1)(ii) Condition and documented no more of participation: Surgical services than 30 days before or 24 42 CFR Â§ 482.51(2) Condition of hours after admission. participation: Surgical services â¢ Updated physical exam 42 CFR Â§ 482.51(6) Condition of and changes to medical participation: Surgical services history must be completed and documented within 24 hours. â¢ A properly executed in- formed consent form must be placed in the patientâs chart except in emergencies. â¢ Operative report describing techniques, findings, and tissues removed or altered must be completed immedi- ately following surgery and signed by surgeon. Medical Medicare Claims Processing â¢ Medical necessity is the Necessity Manual-Chapter 12-Physicians/ overarching criterion for Criteria Non-physician Practitioners- payment along with the Section 30.6.1.A Selection of Level individual requirement of a of Evaluation and Management CPT code. Service Evaluation and Centers for Medicare & Medicaid â¢ Medical record documenta- Management Services, Medicare Learning tion requirements and cod- Services Network, Evaluation and ing considerations. Management Services Medical Record Centers for Medicare & â¢ Provides examples of Insuffi- Documentation Medicaid Services, Medicare cient Documentation Errors. Requirements Learning Network, Fact Sheet, âComplying with Medical Record Documentation Requirementsâ Medicare Medicare Claims Processing â¢ Medicare physicians fee Physician Manual-Chapter 12-Physicians/ schedule, correct coding Practitioners Non-physician Practitioners policy, evaluation and man- agement codes, prolonged services, surgeons, and global surgery charges.
312 TAKING ACTION AGAINST CLINICIAN BURNOUT Clinical Documentation and Coding Regulatory, Accreditation, and Requirements Coding Citations Brief Description The Joint The Joint Commission Standard, â¢ Requirements for complet- Commission Record of Care, Treatment, and ing and documenting medi- History and Services (RC); RC.01.02.01 cal histories and physical Physical The Joint Commission Standard, exams in accordance with Medical Staff (MS); MS.01.01.01, state law and hospital policy EP 16 must be included in the medical staff bylaws. The Joint The Joint Commission Standard, â¢ Addresses record content Commission Information Management (IM); requirements for operative Operative IM.6.30 or other procedures and Report moderate or deep sedation or anesthesia. ICD-10-CM International Classification of â¢ Contains codes for diseases, Official Diseases, Tenth Revision (ICD- signs and symptoms, abnor- Guidelines for 10) https://www.cdc.gov/nchs/icd/ mal findings, complaints, Coding and data/10cmguidelines-FY2019-final. social circumstances, and Reporting pdf external causes of injury or diseases.