Appendix B
Medicare Program, The Joint Commission, and International Classification of Diseases, Tenth Revision, Clinical Documentation and Coding Requirements
Clinical Documentation and Coding Requirements | Regulatory, Accreditation, and Coding Citations | Brief Description |
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Medical Record Services-Documentation | 42 CFR § 482.24(c), Condition of participation: Medical record services |
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Medical Record Services-Orders | 42 CFR § 482.24(c)(3)(i), Condition of participation: Medical record services 42 CFR § 482.24(c)(3)(ii), Condition of participation: Medical record services 42 CFR § 482.24(c)(3)(iii), Condition of participation: Medical record services |
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Clinical Documentation and Coding Requirements | Regulatory, Accreditation, and Coding Citations | Brief Description |
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Medical Record Services-History and Physical | 42 CFR § 482.24(c)(4)(i)(A), Condition of participation: Medical record services 42 CFR § 482.24(c)(4)(i)(B), Condition of participation: Medical record services |
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Medical Record Services-Discharge Summary | 42 CFR § 482.24(c)(4)(vii) and (viii), Condition of participation: Medical record services |
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Medical Record Services-Discharge Planning | 42 CFR § 482.43(c)(6)(iii) Condition of participation: Discharge planning |
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Clinical Documentation and Coding Requirements | Regulatory, Accreditation, and Coding Citations | Brief Description |
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Surgical Services | 42 CFR § 482.51(1)(i) Condition of participation: Surgical services 42 CFR § 482.51(1)(ii) Condition of participation: Surgical services 42 CFR § 482.51(2) Condition of participation: Surgical services 42 CFR § 482.51(6) Condition of participation: Surgical services |
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Medical Necessity Criteria | Medicare Claims Processing Manual-Chapter 12-Physicians/Non-physician Practitioners-Section 30.6.1.A Selection of Level of Evaluation and Management Service |
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Evaluation and Management Services | Centers for Medicare & Medicaid Services, Medicare Learning Network, Evaluation and Management Services |
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Medical Record Documentation Requirements | Centers for Medicare & Medicaid Services, Medicare Learning Network, Fact Sheet, “Complying with Medical Record Documentation Requirements” |
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Medicare Physician Practitioners | Medicare Claims Processing Manual-Chapter 12-Physicians/Non-physician Practitioners |
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Clinical Documentation and Coding Requirements | Regulatory, Accreditation, and Coding Citations | Brief Description |
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The Joint Commission History and Physical | The Joint Commission Standard, Record of Care, Treatment, and Services (RC); RC.01.02.01 The Joint Commission Standard, Medical Staff (MS); MS.01.01.01, EP 16 |
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The Joint Commission Operative Report | The Joint Commission Standard, Information Management (IM); IM.6.30 |
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ICD-10-CM Official Guidelines for Coding and Reporting | International Classification of Diseases, Tenth Revision (ICD10) https://www.cdc.gov/nchs/icd/data/10cmguidelines-FY2019-final.pdf |
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