Coding, Classification and Reimbursement

Documentation requirements to code OP hospital-based dialysis

  • 1.  Documentation requirements to code OP hospital-based dialysis

    Posted 12 days ago

    Hi all ~
    I'm looking for guidelines (LCD and/or NCD) that will provide the documentation requirements for services rendered in a hospital-based OP dialysis unit. Specifically I am looking for information as to whether or not a provider must provide a dialysis note for routine OP dialysis services.  I see that from a physician coding/billing perspective the provider must document a note and must be face-to-face with the patient, however, I'm not looking for the provider/physician component, only the hospital component - is the standard monthly nursing dialysis note sufficient, along with the physician's order for dialysis, to code from?

    Appreciate any insight and guidelines you can share.  Thanks in advance ~

    Lynn A. Wall, MBA, RHIT, CCS
    AHIMA Approved ICD-10-CM/PCS Trainer
    Interim Coding Supervisor
    Maricopa Integrated Health System