I know what you're talking about. It's called, "stand-alone" documentation, meaning that the record for a particular service must stand on its own, without other record contents to necessarily "prop up" its coding.
Recently I've tried to explain this to several people, but the information is scant. I thought this was a bedrock of outpatient and physician coding, but some coders seem to take their liberties at dragging in external information. I think this poses an ethical question.
Here's a previous post on the issue, presumably from this forum.
There's a passing reference it here:
Again, passing reference:
You aren't alone in knowing this to be "true" but struggling to find an authority that lays it out clearly.
Sorry I couldn't be of more help. Let me know if you find something I should be using.
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