"If a resident is evaluated by a physician off-site (e.g., while undergoing dialysis or radiation therapy), it can be coded as a physician visit. Documentation of the physician's evaluation should be included in the clinical record. The physician's evaluation can include partial or complete examination of the resident, monitoring the resident for response to the treatment, or adjusting the treatment as a result of the examination."
To be sure that this requirement is met, I recommend that your facility request a copy of the notes pertaining to the visit that the physician maintains in his or her office chart. Alternatively, the physician's office might be willing to provide notes on the facility's form if you fax them a blank copy of the form.
Rena
Subj: outside MD visits
Date: 12/24/03 10:41:55 AM Pacific Standard Time
From: [EMAIL PROTECTED]
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Sent from the Internet
I had a medicare resident go out to a followup appointment with her orthopedic surgeon. The ONLY documentation I have is a nurses note that says she went, and 4 written prescriptions from the MD. It happened DURING the assessment period. Is this enough to count this as a doctor's visit????
Rena R. Shephard, MHA, RN, FACDONA, RAC-C
Chair, American Association of Nurse Assessment Coordinators
[EMAIL PROTECTED]
