Wiki Reference for each note needing to stand alone

[Bernadette10]

I know this question has been asked before, but I can't find a reference stating that each note needs to stand alone. This is for a subsequent consultation note/subsequent hospital care by a consulting physician (surgeon). He thinks that since he documented the diagnosis on his initial note, he doesn't need one on the subsequent notes for the same hospital stay. I looked in the Medicare claims processing manual for chapter 12, section 30.6 evaluation and management services but didn't find it: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf

Any help is appreciated!

 

[thomas7331]

There isn't a single reference that states this, that I'm aware, but there are many compliance articles that address this and specify that it is not correct coding to draw a diagnosis from a previous encounter. It's just basic correct coding that assignment of a diagnosis is always based on the current encounter - if you look through the ICD-10 guidelines, the word 'encounter' occurs throughout, perhaps hundreds of times - all coding must be drawn from the documentation for that particular encounter that is being reported. Because a patient's diagnosis can change from one encounter to the next, and because providers may have different assessments of what the diagnosis is, a coder cannot assign codes based on notes from different encounters. A coder can only report the conditions that exist, as per what was is documented by the physician, at the particular encounter that is being coded.