Need Assistance

sabullocksabullock
in CDI Talk Archive
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

  • arsusott@msn.comarsusott@msn.com
    Not sure if this helps but this is from Coding Clinic maybe you already have it:)


    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.
  • ctrygarctrygar
    edited May 2016
    I have a question for anyone. I am curious to know if anyone has an LPN working in the CDI role or is everyone an RN. Thanks in advance for your input.
    cheri
  • sharon.colesharon.cole
    edited May 2016
    We use RNs or RHITs.
    Sharon
  • cmclose@saintfrancis.comcmclose@saintfrancis.com
    edited May 2016
    It is just me in my dept~ so far :)

    Claudine Hutchinson RN
    Clinical Documentation Improvement Specialist
    Children's Hospital at Saint Francis
    Email: chutchinson@saintfrancis.com
    Office: (918) 502-6603
    Pager: 98-1001
  • fishdl@shands.ufl.edufishdl@shands.ufl.edu
    edited May 2016
    We are fortunate to have a diverse group working in the CDI role - 4
    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
  • dbutlerdbutler
    edited May 2016
    I do seem to recall 'talking' with someone a year or two ago who was an
    LPN and working in the CDI role.
    Definitely the exception though.
    Don
  • ctrygarctrygar
    edited May 2016
    Thank you all for your assistance
    cheri
  • paxnerospaxneros
    edited May 2016
    We have two and they are excellent! Unfortunately we cannot offer an RNs salary. This position is a promotion for most LPNs. Our facility is moving towards all RNs On the floor and there are many LPNs looking for work. I have always had positive experiences with the capability of LPNs in coding, UM, and now CDI.

    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
  • cbarnescbarnes
    edited May 2016
    All RN's here. Charlene
  • murpca2murpca2
    I am an LPN and am currently the only person in this department. When I started three years ago there was one RN and myself. She left 2 years ago and her position has not been filled as of yet. I took the test for my CCDS last Sept. and passed. We will be expanding in the very near future to a staff of 4 and the facility is recruiting for RN's. I will be the exception to the rule.

    Cathie Murphree LPN, CCDS
    Documentation Improvement Specialist/HIM
    PeaceHealth St. Joseph Medical Center
    (360)788-6300 ext. 3429
    CMurphree@peacehealth.org
    www.peacehealth.org
  • mahmed1mahmed1
    edited May 2016
    if your facility looking for some good candidate please let me know I know few excellent candidate.

    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
  • robert.hodges2robert.hodges2
    edited May 2016
    I don't have a reference but as you probably know already the VA has a complete EMR that is integrated between all VA facilities.

    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
  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited May 2016
    Shelia: The regulations and policy stated by Robert mimic closely the JCAHO requirements for an 'interval H&P' - You might want to discuss this with the HIM Director. In my opinion, if an 'interval H&P' is accepted as per the conditions nicely referenced by Robert, any conditions stated in that interval H&P that qualify for a reportable condition (chronic diastolic CHF, CKD Stage IV) may be considered for reporting.


    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
  • vdavis2vdavis2
    edited May 2016
    I know this is not specific to CDI, but more the regulatory side of documentation. Does anyone have a good procedure consent form that contains the layman's term piece and informed consent on one document? Our CDI program performs various audits periodically including blood transfusion cases and some of the surgery cases. Currently our nursing staff does the consent with the patient after the MD has had a chance to discuss the procedure with the patient. We want to see what form other hospitals are using and to find out who completes the consent. (I think it is just as easy for the MD to take it into the room with them when they go to discuss the procedure with the pt. The MD would then sign it right after the patient. Our MD's have a slightly different opinion about the "ease" of that process, so we are taking suggestions.)

    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
  • mdomineseymdominesey
    edited May 2016
    The MDs are putting themselves at risk by having someone else complete the consent process. They are essentially verifying by signing before or after the nurse presenting the document to the patient that the patient had every opportunity to question and review the risk/benefits of the surgery with the physician. Doesn't seem to be a best practice IMHO.

    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.hodges2robert.hodges2
    edited May 2016
    VA policy is that the provider performing the procedure must obtain the consent. This includes blood transfusions as well. I can't share our forms since they are all electronic and the patient and/or their legal representative signs them after review on an electronic signature pad. That way they are in the EMR and viewable immediately. Here medical records does a concurrent review of consent forms for ambulatory surgery and they do ensure that it is signed by the provider and patient.

    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
Sign In or Register to comment.