| Providers in AR, CO, LA, MS, NM, OK, TX, Indian Health & Veteran Affairs | |
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This checklist is intended to provide healthcare providers with a reference for use when responding to medical documentation requests for services rendered and hospital admissions to treat malnutrition. Healthcare providers retain responsibility to submit complete and accurate. documentation.
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Documentation descriptions |
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Please submit a mandatory advanced beneficiary notice (ABN) if issued. |
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CMS 1450 (UB-04) Uniform Bill form/ Itemized bill. |
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Physician admission note/History & Physical, emergency department documentation, progress notes, and discharge summary supporting the identification, diagnosis, and treatment plans for the diagnosis of severe protein-calorie malnutrition. |
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Physician documentation of physical appearance, history of nutritional intake, and weight history to support severe protein-calorie malnutrition. |
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Physician documentation of interventions implemented along with any changes for the treatment of severe protein-calorie malnutrition. |
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Physician orders. |
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All progress notes, including nurses, therapies, dietician/nutritional assessment, and other multi-disciplines reflecting state of severe protein-calorie malnutrition. |
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All test results including pertinent lab results, clinical findings, operative/procedure notes, and consult notes to support diagnosis of severe protein-calorie malnutrition. |
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Infusion therapy flow sheets. |
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Medication administration records (MAR) and treatment administration records (TAR) | This checklist was created as an aid to assist providers. This aid is not intended as a replacement for the documentation requirements published in national or local coverage determinations, or CMS documentation guidelines. It is the responsibility of the provider of services to ensure the correct, complete, and thorough submission of documentation.
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