I have never seen a reference stating that BMI's can only be coded if documented by a "licensed clinician". It's my own coding department's interpretation of Coding Clinic 2nd qtr 2010 p. 15.
Sorry to be confusing. We have a situation here of an ID nurse who pre-populated a query for catheter related uti including the actual relationship and the organism and then left an email note, post-it note and phone call requesting that a specific MD sign it. Wrong, wrong, wrong. We do not LEAD physicians.
That is the reference/citation I am searching for. I need to prove this to her and some leadership people. Therefore, I want a citation.
Again, sorry for the confusion.
Donna Kent, RN, BSN, CCDS Manager, Clinical Documentation Integrity Program Clinical Quality and Accreditation Torrance Memorial Medical Center ph.:310 784-6884 fax:310 784-6899 donna.kent@tmmc.com
I would show them AHIMA's practice brief, "Managing an Effective Query Process." That is where we find the guidelines against leading queries, and AFAIK, that is the gold standard for query policies. As far as who may diagnose, that comes from ICD-9 CM Official Guidelines for Coding and Reporting, starting with, "In the context of these guidelines, the term provider is used throughout the guidelines to mean physician or any qualified health care practitioner who is legally accountable for establishing the patient’s diagnosis. Only this set of guidelines, approved by the Cooperating Parties, is official." I hope that's what you're seeking.
Renee
Linda Renee Brown, RN, CCRN, CCDS Senior Consultant, CDI/Nursing Jacobus Consulting, Inc.
Donna Kent, RN, BSN, CCDS Manager, Clinical Documentation Integrity Program Clinical Quality and Accreditation Torrance Memorial Medical Center ph.:310 784-6884 fax:310 784-6899 donna.kent@tmmc.com
Comments
Vivian
pre-populated a query for catheter related uti including the actual
relationship and the organism and then left an email note, post-it note
and phone call requesting that a specific MD sign it. Wrong, wrong,
wrong. We do not LEAD physicians.
That is the reference/citation I am searching for. I need to prove this
to her and some leadership people. Therefore, I want a citation.
Again, sorry for the confusion.
Donna Kent, RN, BSN, CCDS
Manager, Clinical Documentation Integrity Program
Clinical Quality and Accreditation
Torrance Memorial Medical Center
ph.:310 784-6884 fax:310 784-6899
donna.kent@tmmc.com
Renee
Linda Renee Brown, RN, CCRN, CCDS
Senior Consultant, CDI/Nursing
Jacobus Consulting, Inc.
Ahima practice brief.
Donna Kent, RN, BSN, CCDS
Manager, Clinical Documentation Integrity Program
Clinical Quality and Accreditation
Torrance Memorial Medical Center
ph.:310 784-6884 fax:310 784-6899
donna.kent@tmmc.com