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Supporting documentation requirements

  1. #1
    Question Supporting documentation requirements
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    Does anyone have, in writing, rules on using dx not listed in the note you are coding from?

    This seems like a no brainer to me and everyone I have asked but the only thing I can find is regarding using history from other notes. Which of course you have to document the date of and name of the form you are referencing.

    We have a coder that is coding surgeries. The surgical documentation only supports say 1 dx and no reference is made to any other documentation. She is going thru the entire medical record and pulling out dx and using them. She says that since it is in the record she can use it. The doctor is supporting her and they will not change anything until we provide something in writing showing this is incorrect.

    Any help is greatly appreciated.

    Laura, CPC, CPMA, CEMC

  2. #2
    Louisville, KY

    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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