APN Services Clause Samples

APN Services a. The APN, in any and all settings, shall keep such legible individual written records and /or electronic medical records (EMR) as are necessary to fully disclose the kind and extent of service(s) provided, the procedure code being billed and the medical necessity for those services. b. Documentation of services performed by the APN shall include, as a minimum: i. The date of service; ii. The name of the beneficiary; iii. The beneficiary’s chief complaint(s), reason for visit; iv. Review of systems; v. Physical examination; vi. Diagnosis; vii. A plan of care, including diagnostic testing and treatment(s); viii. The signature of the APN rendering the service; and ix. Other documentation appropriate to the procedure code being billed. (See N.J.A.C. 10:58A-4, HCPCS Codes.) c. In order to receive reimbursement for an initial visit, the following documentation, at a minimum, shall be placed on the medical record by the APN, regardless of the setting where the examination was performed: i. Chief complaint(s); ii. A complete history of the present illness, with current medications and review of systems, including recordings of pertinent negative findings; iii. Pertinent medical history; iv. Pertinent family and social history; v. A complete physical examination; vi. Diagnosis; and vii. Plan of care, including diagnostic testing and treatment. d. In order to document the record for reimbursement purposes, the progress note for routine office visits or follow up care visits shall include the following: i. In an office or residential health care facility: 1) The beneficiary’s chief complaint(s), reason for visit; 2) Pertinent medical, family and social history obtained; 3) Pertinent physical findings; 4) All diagnostic tests and/or procedures ordered and/or performed, if any, with results; and 5) A diagnosis. ii. In a hospital or nursing facility setting: 1) An update of symptoms; 2) An update of physical symptoms; 3) A resume of findings of procedures, if any done; 4) Pertinent positive and negative findings of lab, X-ray or any other test; 5) Additional planned studies, if any, and the reason for the studies; and 6) Treatment changes, if any. e. To qualify as documentation that the service was rendered by the APN during an inpatient stay, the medical record shall contain the APN’s notes indicating that the APN personally: i. Reviewed the beneficiary’s medical history with the beneficiary and/or his or her family, depending upon the medical situation; ii. Performe...