Need Assistance
I am looking for the specific reference in CMS publications that defines a provider. I am trying to show who a coder can take clinical information from to code. I know the rules but need the specific site to reference. Can anyone help? Thanks
Comments
AHA Coding Clinicâ for ICD-9-CM, 4Q 2004, Volume 21, Number 4, Page 138
Question:
Can a coder report new diagnoses that are documented in the medical record by mid-level providers such as nurse practitioners and physician assistants, but not confirmed by the attending physician in the inpatient setting?
Answer:
It would be appropriate to use the health record documentation of other providers, such as nurse practitioners and physician assistants as the basis for code assignment to report new diagnoses, if they are considered legally accountable for establishing a diagnosis within the regulations governing the provider and the facility. The Official Guidelines for Coding and Reporting define a provider as the individual legally accountable for establishing a diagnosis.
cheri
Sharon
Claudine Hutchinson RN
Clinical Documentation Improvement Specialist
Children's Hospital at Saint Francis
Email: chutchinson@saintfrancis.com
Office: (918) 502-6603
Pager: 98-1001
RNs, 1 RHIT, 1 CPC, 2 CCS w/CCDS.
The experience, knowledge, and skill set of each individual contributes
to the strength & success of the team!
Donna Fisher, CCS, CCDS
Lead Clinical Documentation Improvement Specialist
Health Information Management
Shands Healthcare at the University of Florida
352-265-0680 Ext 48769
fishdl@shands.ufl.edu
LPN and working in the CDI role.
Definitely the exception though.
Don
cheri
They perform all functions of CDI professionals. They are responsible for educating physicians, making presentations regarding CDI. They are expected to become certified after 1 year of employment in the position. Just recently one of our LPNs became a CCDS.
Again, it goes back to how your facility wants to set up its CDI model and the personnel who fill those roles. Choosing the right "fit" depends on what those people nhave to offer. Its up ton the individual and their background and experience.
NBrunson, RHIA, CCDS
Cathie Murphree LPN, CCDS
Documentation Improvement Specialist/HIM
PeaceHealth St. Joseph Medical Center
(360)788-6300 ext. 3429
CMurphree@peacehealth.org
www.peacehealth.org
thanks,
MA
Sincerely,
Mohammad Ahmed, M.D, CCS, CCDS,
Certified Clinical Documentation Specialist
Bronx Lebanon Hospital Center
Health Information Management
1650 Grand Concourse
Bronx, NY 10457
Phone: 718-518-5119
Cell : 347-307 5403
Fax: 718-518-5634
Email: mahmed1@bronxleb.org
VA policy is that the H&P can be done up to 30 days prior to the encounter but, all information in that H&P must be reviewed and verified and any changes to that H&P documented on the day of the actual encounter. And when they reference the old H&P, they must indicate the date of that H&P they are referencing. This would include a patient who was discharged and readmitted for the same complaint within 30 days. In practice on the acute care side, a new H&P is done every time.
What we do here for ambulatory surgery is we have a two part H&P. Part one is done over the phone and a review of the record and consists of the past history, medications, and what procedure they are scheduled for. Part two is done on arrival and has a area where part one is verified and/or updated, current physical exam and vital signs plus any other pertinent information.
I know it's not the reference you are looking for, but it may help some.
Robert
Robert S. Hodges, BSN, MSN, RN, CCDS
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602
P: 989-497-2500 x13101
F: 989-321-4912
E: Robert.Hodges2@va.gov
“Patriotism is easy to understand in America; it means looking out for yourself by looking out for your country" Calvin Coolidge
Paul Evans, RHIA, CCS, CCS-P, CCDS
Supervisor, Clinical Documentation Integrity, Quality Department
California Pacific Medical Center
2351 Clay #243
San Francisco, CA 94115
Cell: 415.637.9002
Fax: 415.600.1325
Ofc: 415.600.3739
evanspx@sutterhealth.org
Thanks everyone!-V
Vicki S. Davis, RN CDS
Clinical Documentation Improvement Manager
Health Information Management Department
Alamance Regional Medical Center
Office (336) 586-3765
Ascom Mobile (336) 586-4191
Fax (336) 538-7428
vdavis2@armc.com
"The difference between the right word and the almost right word is the difference between lightning and the lightning bug."- Samuel "Mark Twain" Clemens
Mark
Mark N. Dominesey, RN, BSN, MBA, CCDS, CDIP
Clinical Documentation Excellence
Sr. Clinical Documentation Improvement Specialist
Sibley Memorial Hospital
Information Technology
5255 Loughboro Rd NW
Washington DC, 20016-2695
W: 202.660.6782
F: 202.537.4477
mdominesey@sibley.org
http://www.sibley.org
Robert
Robert S. Hodges, BSN, MSN, RN, CCDS
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602
P: 989-497-2500 x13101
F: 989-321-4912
E: Robert.Hodges2@va.gov
“Patriotism is easy to understand in America; it means looking out for yourself by looking out for your country" Calvin Coolidge