Wiki Provider refer to H & P for dx

[nanc512]

I am looking for documentation regarding a provider referring to an H & P for diagnoses. I have found very little on CMS. Is there something out there that states they can not do this? I found a few things on a stand alone note, but I am sure they are thinking since the dx are on the H & P, that is okay. Aside from the fact, that the dx changes over the course of the hospital stay.

I would appreciate any help, been looking for this for awhile.

Thanks.

Nancy

 

[Pam Warren]

The quick and dirty answer is 'it depends'.

If you're coding an outpatient (or inpatient) facility stay,then the H&P and other physician-authored notes are part of the admission, and you can use them to code from.

In the professional-fee world, each professional encounter/visit and the corresponding documentation for that encounter/visit must stand alone. So you should not use another note that's also going to be billed out for payment in order to code a separate encounter/visit. It's a great opportunity to educate your surgeon to give you a decent "indication for surgery", so that you aren't tempted to rely on the H&P to find out why he/she opened someone up.