Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being (2019)

Chapter: Appendix B: Medicare Program, The Joint Commission, and International Classification of Diseases, Tenth Revision, Clinical Documentation and Coding Requirements

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Suggested Citation: "Appendix B: Medicare Program, The Joint Commission, and International Classification of Diseases, Tenth Revision, Clinical Documentation and Coding Requirements." National Academies of Sciences, Engineering, and Medicine. 2019. Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being. Washington, DC: The National Academies Press. doi: 10.17226/25521.
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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
Medical Record Services-Documentation 42 CFR § 482.24(c), Condition of participation: Medical record services
  • Content of record.
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
  • Orders reviewed and approved by medical staff and nursing and pharmacy leadership.
  • Orders are consistent with nationally recognized and evidence-based guidelines.
  • Orders are dated, timed, and authenticated promptly.
Page 310 Cite
Suggested Citation: "Appendix B: Medicare Program, The Joint Commission, and International Classification of Diseases, Tenth Revision, Clinical Documentation and Coding Requirements." National Academies of Sciences, Engineering, and Medicine. 2019. Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being. Washington, DC: The National Academies Press. doi: 10.17226/25521.
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Clinical Documentation and Coding Requirements Regulatory, Accreditation, and Coding Citations Brief Description
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
  • Medical history and physical examination.
  • Updated changes to history and physical within 30 days.
  • Admitting diagnosis.
  • Consultative evaluations and clinical findings.
  • Documentation of complications, unfavorable reactions to drugs and anesthesia, and hospital-acquired infections.
  • Documentation of properly executed consent forms.
  • Documentation necessary to monitor patient’s condition, including orders, nursing notes, treatment reports, medication records, radiology and laboratory reports, and vital signs.
Medical Record Services-Discharge Summary 42 CFR § 482.24(c)(4)(vii) and (viii), Condition of participation: Medical record services
  • Documentation of discharge summary, hospitalization outcome, case disposition, and provisions for follow-up care.
  • Documentation of a final diagnosis with completion of the medical record within 30 days.
Medical Record Services-Discharge Planning 42 CFR § 482.43(c)(6)(iii) Condition of participation: Discharge planning
  • Documentation of a list of home health aides or skilled nursing facilities that are 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.
Page 311 Cite
Suggested Citation: "Appendix B: Medicare Program, The Joint Commission, and International Classification of Diseases, Tenth Revision, Clinical Documentation and Coding Requirements." National Academies of Sciences, Engineering, and Medicine. 2019. Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being. Washington, DC: The National Academies Press. doi: 10.17226/25521.
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Clinical Documentation and Coding Requirements Regulatory, Accreditation, and Coding Citations Brief Description
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
  • Medical history and physical exam must be completed and documented no more than 30 days before or 24 hours after admission.
  • Updated physical exam and changes to medical history must be completed and documented within 24 hours.
  • A properly executed informed consent form must be placed in the patient’s chart except in emergencies.
  • Operative report describing techniques, findings, and tissues removed or altered must be completed immediately following surgery and signed by surgeon.
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
  • Medical necessity is the overarching criterion for payment along with the individual requirement of a CPT code.
Evaluation and Management Services Centers for Medicare & Medicaid Services, Medicare Learning Network, Evaluation and Management Services
  • Medical record documentation requirements and coding considerations.
Medical Record Documentation Requirements Centers for Medicare & Medicaid Services, Medicare Learning Network, Fact Sheet, “Complying with Medical Record Documentation Requirements”
  • Provides examples of Insufficient Documentation Errors.
Medicare Physician Practitioners Medicare Claims Processing Manual-Chapter 12-Physicians/Non-physician Practitioners
  • Medicare physicians fee schedule, correct coding policy, evaluation and management codes, prolonged services, surgeons, and global surgery charges.
Page 312 Cite
Suggested Citation: "Appendix B: Medicare Program, The Joint Commission, and International Classification of Diseases, Tenth Revision, Clinical Documentation and Coding Requirements." National Academies of Sciences, Engineering, and Medicine. 2019. Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being. Washington, DC: The National Academies Press. doi: 10.17226/25521.
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Clinical Documentation and Coding Requirements Regulatory, Accreditation, and Coding Citations Brief Description
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
  • Requirements for completing and documenting medical histories and physical exams in accordance with state law and hospital policy must be included in the medical staff bylaws.
The Joint Commission Operative Report The Joint Commission Standard, Information Management (IM); IM.6.30
  • Addresses record content requirements for operative or other procedures and moderate or deep sedation or anesthesia.
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
  • Contains codes for diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases.
Page 309 Cite
Suggested Citation: "Appendix B: Medicare Program, The Joint Commission, and International Classification of Diseases, Tenth Revision, Clinical Documentation and Coding Requirements." National Academies of Sciences, Engineering, and Medicine. 2019. Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being. Washington, DC: The National Academies Press. doi: 10.17226/25521.
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Page 310 Cite
Suggested Citation: "Appendix B: Medicare Program, The Joint Commission, and International Classification of Diseases, Tenth Revision, Clinical Documentation and Coding Requirements." National Academies of Sciences, Engineering, and Medicine. 2019. Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being. Washington, DC: The National Academies Press. doi: 10.17226/25521.
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Page 310
Page 311 Cite
Suggested Citation: "Appendix B: Medicare Program, The Joint Commission, and International Classification of Diseases, Tenth Revision, Clinical Documentation and Coding Requirements." National Academies of Sciences, Engineering, and Medicine. 2019. Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being. Washington, DC: The National Academies Press. doi: 10.17226/25521.
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Page 311
Page 312 Cite
Suggested Citation: "Appendix B: Medicare Program, The Joint Commission, and International Classification of Diseases, Tenth Revision, Clinical Documentation and Coding Requirements." National Academies of Sciences, Engineering, and Medicine. 2019. Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being. Washington, DC: The National Academies Press. doi: 10.17226/25521.
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