In order to code to the highest level of specificity, Coding Conventions and Guidelines are followed. This requires documentation to be clearly evident and supportive of each code recommended. That documentation, for coding purposes of a Start of Care, would include information found in the OASIS Integrated Assessment, Medication Profile, Physician Orders, History and Physical, Referral Form (if available), and Discipline Specific Care Plan with accompanying Orders and Goals.

The initial visit note should clearly reflect the purpose specific to the goal expectations of the POC. There should be congruence between the Initial OASIS assessment, the patient careplan, and the discipline specific orders and goals.

Goals of Documentation

  • Provide evidence that the care given meets clinical standards
  • Justify reimbursement for the payor
  • Provide protection from liability
  • Means of communication among individuals providing services
  • Provide accurate data regarding care for specific patient and diagnostic populations.

The MasterCoding™ team remains current with industry changes, regulations, and surveyor protocols. MasterCoding™ assists your agency to reduce risk!

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