Wiki Stand alone/encounter

[nabernhardt]

I am trying to find documentation that states we have to treat each encounter by itself and cannot use previous information or history that is documented for a different encounter. To code meaning each encounter stands alone. Does anyone have anywhere I can find this as a coding rule/guideline?

 

[SherryMiller]

A provider can reference a prior history and notate any interval changes. Where we need to be very careful is with cloning of records in an EMR. The OIG has added the auditing of records because of this to their workplan.
Evaluation and Management Services: Potentially Inappropriate Payments
We will assess the extent to which CMS made potentially inappropriate payments for E/M services and the consistency of E/M medical review determinations. We will also review multiple E/M services for the same providers and beneficiaries to identify electronic health records (EHR) documentation practices associated with potentially improper payments. Medicare contractors have noted an increased frequency of medical records with identical documentation across services.Medicare requires providers to select the code for the service based upon the content of the service and have documentation to support the level of service reported. (CMS’s Medicare Claims Processing Manual, Pub. No. 100-04, ch. 12, § 30.6.1.) (OEI; 04-10-00181; 04-10-00182; expected issue date: FY 2013; work in progress)

 

[Evelyn Kim]

I would recommend checing out the documentation guidelines on the CMS website. I have found this information most helpful with the providers I work with. Also review the 95/97 Documentation Guidelines for Evaluation and Management Services IEvaluation and Management Services manual).

Hope this helps.