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I hope I can explain this correctly. I have a question regarding encounter data validation - medical record reviews for an inpatient scenario. A patient was admitted inpatient for psychiatric issues. They were inpatient for a week from beginning date of service to end date of service/discharge (Ex. 7/4/2020 - 7/11/2020). This is a subsequent coding setting because the pt received psychiatric care/observation/services every day, and documentation shows the level of care including medication management and counseling for each day. Now, the review I'm doing is requesting the dx and procedure codes for dos and end date of service on 7/7...not for the entire inpatient stay. If there is documentation of services for the encounter on 7/7 that correlate with the overall inpt stay, would it be reasonable to validate this encounter with the final dx codes along with the CPT code for subsequent care? Basically, can I use the dx code(s) and subsequent procedure code for the requested encounter date of 7/7? I'm thinking, yes since the review is asking for DOS on 7/7 and not the BEGINNING DOS which is 7/4. Any help or guidance you may have would be graciously appreciated.



Coeur d'Alene, Idaho
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Are you coding for a facility or the provider? If you're coding for the provider, the documentation stands alone, meaning that the note for 7/7 should only reflect the CPT and diagnoses that were documented on that DOS.