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Pulling DX's from Previous Notes

  1. Default Pulling DX's from Previous Notes
    Medical Coding Books
    Can the previous OV note be used to pull diagnosis from to support a procedure at a later date of service?

  2. #2
    Quote Originally Posted by jammiesrl View Post
    Can the previous OV note be used to pull diagnosis from to support a procedure at a later date of service?
    The short answer is no...

    The diagnosis/indication for surgery should be clearly indicated on the current note. If it's not, the provider needs to make an addendum, and add that information. Each note should be able to stand alone. Sometimes you may need to use a previous note to support medical necessity later on (like, in an appeal), but that's more to show the history of an ongoing problem, rather than using the old note to determine the reason for the current encounter.

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