PFSH

Post here your questions regarding auditing ,coding, documentation, and compliance. Also, join in on the conversation- help your fellow auditors and compliance professionals in the industry.

Moderators: Shannon DeConda, NAMAS Moderator

Post Reply
maryv22
Posts: 13
Joined: Wed Apr 27, 2016 11:00 am

Tue Aug 15, 2017 9:52 am

Regarding: Past, Family, Social History

Can an Attending Physician from one specialty refer to another Attending's note in a different specialty?

ie - Urology Attending referring to Neonatology Attending's note
Social History: Please see Primary service note for complete details completed by John Doe, MD on 6/15/2017
Family History: Please see Primary service note for complete details completed by John Doe, MD on 6/15/2017
User avatar
admin
Site Admin
Posts: 443
Joined: Mon Apr 09, 2012 1:54 pm

Tue Aug 22, 2017 9:19 am

I believe as long as it is a specific record, and that record does not reference another record, then yes. The expectation is that when referenced, the record has the required information.

https://www.cms.gov/Outreach-and-Educat ... 006764.pdf

Your question has been answered by: Omega Renne, CPC, CPCO, CPMA, CEMC, CIMC
Post Reply