Ga. Medicaid Part II Policies & Procedures for Hospital Services § 904

904.1. Identification data includes the patient’s name, address, date of birth, next of kin, and a

number that identifies the patient and the patient’s medical record.

904.2. Medical history completed within twenty-four of admission, including the chief complaint,

details of the present illness, relevant past, social and family histories, and an inventory by

body systems

904.3. Relevant obstetrical records and prenatal information.

904.4. Report of the physical examination, completed within twenty-four of admission;

904.5. A statement of conclusions or impressions drawn from the admission history and physical

examination.

904.6. A statement of the course of action planned for the patient while in the hospital including a

periodic review of the planned course of action, as appropriate

904.7. Diagnostic and therapeutic orders written by medical staff members. Verbal orders must be

authenticated in the manner established by the Rules and Regulations for Hospitals, Chapter

290-9-7-.18(2) (6) (1).

904.8. Appropriate informed consent;

904.9. Clinical observations.

904.10. Progress notes by the medical staff which give a chronological report of the patient’s course

in the hospital and reflect changes in condition and the results of treatment.

904.11. Consultation reports that contain the consultant’s written opinion and reflect, when

appropriate, an actual examination of the patient and the patient’s medical record

904.12. Nursing notes and entries by non-physicians that contain medically relevant observations

and information

904.13. Reports of procedures, tests and their results.

904.14. A preoperative diagnosis recorded prior to surgery by the individual responsible for the

patient.

904.15. Operative report dictated or written on the medical record immediately after surgery

containing a description of the findings, the technical procedures used, the specimens

removed, the postoperative diagnosis, and the name of the primary surgeon and any

assistants.

904.16. Reports of pathology and clinical laboratory examinations, radiology and nuclear medicine

examinations or treatment, anesthesia records, and any other diagnostic or therapeutic

procedures.

904.17. Clinical summary at termination of hospitalization which recapitulates the reason for

hospitalization, the significant findings, and the procedures performed, and treatment

rendered the condition of the patient upon discharge, and any significant instructions given

to the patient and family.

904.18. In teaching hospitals, the medical record must make it clear that the attending physician is

providing professional services independently of the student or resident and that the notes of

the student or resident only reflect his role as student or resident. At a minimum, the medical

record must contain signed or countersigned notes which clearly specify that the physician

personally reviewed the history, gave a physical examination, and confirmed or revised the

diagnosis and prescribed treatment. The attending physician must be recognized by the

member as the member’s personal physician.

904.19. In addition, Physicians’ Current Procedural Terminology, Fourth Edition (CPT-4) coding

and/or HCPCS is required for all outpatient surgical, obstetrical, injectable drugs, diagnostic

laboratory and radiology procedures. Certain codes from these schemes are not accepted by

the Division.

904.20. Hospitals are required to code all relevant diagnoses and all surgical and obstetrical

procedures on all inpatient and outpatient claims submitted to the Division.

904.21. The hospital must select the code(s) that most nearly describe(s) the diagnosis (es) and

procedure(s) performed. When a single code is available for reporting multiple tests of

procedures, that code must be utilized rather than reporting the tests or procedures

individually.

ICD-10-CM and CPT Coding Books may be ordered from:

Superintendent of Documents U.S.

Government Printing Office Washington,

D.C. 20402

Order Department OP054192

American Medical Association

P. O. Box 10950

Chicago, Illinois 60610

904.22. The claim form required by the Division for billing (inpatient and outpatient hospital

services is the National Uniform Billing Form (UB-04). See the Billing Instructions

Appendix O) for the required information to file a claim for hospital services.