Review of diag - Pennsylvania Association of Nurse ...
5794650-23006900PHYSICIAN’S ROLE IN PDPM/ICD-10 DIAGNOSISIMPLEMENTATION & DOCUMENTATION213995265430PHYSICIANS/NP/PA (We need your assistance for the following):Review of diagnosis list (on skilled residents) for all current diagnoses and recent surgeries while in hospitalSpecificity of the diagnoses to include laterality, complication documentationClinical Documentation Improvement process – same as you do in the Acute Hospital; have supporting clinical documentation for the diagnosis for each resident to support accurate coding for CARE & BILLINGClarify any conflicting or lacking documentationMake sure your office is billing diagnoses that match the resident chart00PHYSICIANS/NP/PA (We need your assistance for the following):Review of diagnosis list (on skilled residents) for all current diagnoses and recent surgeries while in hospitalSpecificity of the diagnoses to include laterality, complication documentationClinical Documentation Improvement process – same as you do in the Acute Hospital; have supporting clinical documentation for the diagnosis for each resident to support accurate coding for CARE & BILLINGClarify any conflicting or lacking documentationMake sure your office is billing diagnoses that match the resident chart273685244475WHAT THE FACILITY WILL ASSIST WITHUpon admission of a skilled resident, the MDS Nurse/Clinical Team – Health Information Record Designee will:Obtain the acute H&P/discharge summary/ operation report and/or type surgery upon transfer to the facilityIdentify diagnoses from the acute H&P, discharge summary and facility H&P – and determine active diagnosesUsing the diagnosis worksheet, identify all active diagnoses/conditions – make available for reviewSequence the active diagnoses and select the primary reason for skilled coverage and code using the ICD-10 bookIdentify any diagnoses needing MD clarification with specificity, laterality, or conflicting documentation, addressed per ICD-10 coding requirements/CDIDiagnoses, starting in late June, will need to assure coding for PDPM is being done (as resident could still be in facility 10/1/19)Whenever diagnoses are updated in the computer, print new facesheets/old facesheets are removed and filed/place new facesheets on the chart00WHAT THE FACILITY WILL ASSIST WITHUpon admission of a skilled resident, the MDS Nurse/Clinical Team – Health Information Record Designee will:Obtain the acute H&P/discharge summary/ operation report and/or type surgery upon transfer to the facilityIdentify diagnoses from the acute H&P, discharge summary and facility H&P – and determine active diagnosesUsing the diagnosis worksheet, identify all active diagnoses/conditions – make available for reviewSequence the active diagnoses and select the primary reason for skilled coverage and code using the ICD-10 bookIdentify any diagnoses needing MD clarification with specificity, laterality, or conflicting documentation, addressed per ICD-10 coding requirements/CDIDiagnoses, starting in late June, will need to assure coding for PDPM is being done (as resident could still be in facility 10/1/19)Whenever diagnoses are updated in the computer, print new facesheets/old facesheets are removed and filed/place new facesheets on the chart ................
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