There is a fine line between L98.1 Factitial dermatitis (neurotic excoriation) and F42.4 Excoriation (skin-picking) disorder. Only the physician can make the determination which - or if either - is appropriate for any given patient. Best practices would have you always confirm your diagnoses with the physician. Then you have documentation to support your coding.
There was an excellent webinar from AbilityNetwork.com titled Top Challenges of OASIS-C2 and How to be Prepared. In it, Lisa Selman reviews the requirement to have written documentation from the physician to support your coding. The URL to listen to the archive is: https://attendee.gotowebinar.com/register/1191242062854203395
Here is a paste regarding your question:
M1028 Identify Diagnosis: Documented in Record .Although open communication regarding diagnostic information between the physician and other clinical staff is important, it is also essential that diagnoses communicated verbally be documented in the medical record by the physician (or nurse practitioner, physician assistant, clinical nurse specialist, or other licensed staff if allowable under state licensure laws) to ensure follow-up and coordination of care. .Diagnostic information, including past medical and surgical history obtained from family members and close contacts, must also be documented in the medical record by the physician (or nurse practitioner, physician assistant, clinical nurse specialist, or other authorized licensed staff if allowable under state licensure laws) to ensure validity, follow-up and coordination of care. .Only diagnoses confirmed and documented by the physician (or nurse practitioner, physician assistant, clinical nurse specialist, or other authorized licensed staff if allowable under state licensure laws) should be considered when coding this item.
M1028 Identify Diagnosis: Documented by the physician. .The nurse calls to confirm a diagnosis. It is confirmed. Nurse writes verbal order. -Question: Is that documented by the physician? -Answer: No, it must be documented by the physician to check the box. .When are you going to get that documentation?
Susan Winokur, HCS-D, BCHH-C | Southwest Medical Part of OptumCare Senior Medical Coder, Home Health
8655 South Eastern Avenue, Las Vegas, NV 89123 USA T
Comments
Susan Winokur, HCS-D, BCHH-C | Southwest Medical
Part of OptumCare
Senior Medical Coder, Home Health
8655 South Eastern Avenue, Las Vegas, NV 89123 USA
T
There was an excellent webinar from AbilityNetwork.com titled Top Challenges of OASIS-C2 and How to be Prepared. In it, Lisa Selman reviews the requirement to have written documentation from the physician to support your coding. The URL to listen to the archive is: https://attendee.gotowebinar.com/register/1191242062854203395
Here is a paste regarding your question:
M1028 Identify Diagnosis: Documented in Record
.Although open communication regarding diagnostic information between the physician and other clinical staff is important, it is also essential that diagnoses communicated verbally be documented in the medical record by the physician (or nurse practitioner, physician assistant, clinical nurse specialist, or other licensed staff if allowable under state licensure laws) to ensure follow-up and coordination of care.
.Diagnostic information, including past medical and surgical history obtained from family members and close contacts, must also be documented in the medical record by the physician (or nurse practitioner, physician assistant, clinical nurse specialist, or other authorized licensed staff if allowable under state licensure laws) to ensure validity, follow-up and coordination of care.
.Only diagnoses confirmed and documented by the physician (or nurse practitioner, physician assistant, clinical nurse specialist, or other authorized licensed staff if allowable under state licensure laws) should be considered when coding this item.
M1028 Identify Diagnosis: Documented by the physician.
.The nurse calls to confirm a diagnosis. It is confirmed. Nurse writes verbal order.
-Question: Is that documented by the physician?
-Answer: No, it must be documented by the physician to check the box.
.When are you going to get that documentation?
Susan Winokur, HCS-D, BCHH-C | Southwest Medical
Part of OptumCare
Senior Medical Coder, Home Health
8655 South Eastern Avenue, Las Vegas, NV 89123 USA
T
Lisa