AHIMA Documentation Integrity Practitioner (CDI) CDIP Question # 21 Topic 3 Discussion

The entity that has the following regulation is the Centers for Medicare & Medicaid Services (CMS), which is the federal agency that oversees the Medicare and Medicaid programs and sets the Conditions of Participation (CoPs) and Conditions for Coverage (CfCs) for health care organizations that participate in these programs. The regulation that requires a medical history and physical examination be completed and documented for each patient no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services, is part of the CoPs for Hospitals, which are located in 42 CFR § 482.24. This regulation was revised in 2007 to align with the Joint Commission’s standard and to provide more flexibility and consistency for hospitals and practitioners. (CDIP Exam Preparation Guide)

References:

CDIP Exam Content Outline1

CDIP Exam Preparation Guide2

42 CFR § 482.243