AAPC - Back to school
Results 1 to 3 of 3

Thread: Stand alone/encounter

  1. #1

    Default Stand alone/encounter

    AAPC: Back to School
    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?

  2. #2


    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)
    Sherry Miller, MBA/HCM, CPC, CEMC
    Epic Management, LP

  3. #3
    Join Date
    Apr 2007
    San Antonio, TX


    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.
    Revenue Cycle Supervisor

Similar Threads

  1. What does HCC stand for?
    By codecrazy in forum Medical Coding General Discussion
    Replies: 6
    Last Post: 11-23-2015, 03:34 AM
  2. Stand Up MRI
    By sm9jack in forum Medical Coding General Discussion
    Replies: 0
    Last Post: 01-06-2009, 12:49 AM
  3. stand alone documents
    By sundaey in forum Medicare Regulations
    Replies: 0
    Last Post: 10-03-2008, 12:34 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts

Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.