"Notes must stand alone"

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JJones
Posts: 38
Joined: Sat Dec 20, 2014 9:32 pm

Mon Mar 06, 2017 7:43 pm

Hello! We are trying to locate where the phrase "all notes must stand alone". We see this statement often, but are unclear as to where it comes from. Is it a CMS directive? We have been unable to find anything while searching their website. Thank you in advance for any guidance and/or direction you can give.
bill.wong
Posts: 32
Joined: Wed Aug 17, 2016 6:02 pm

Sat Apr 22, 2017 1:15 am

Hello Jjones.

I finally found where the phrase came from. It is from First Coast Service Options, Inc. (FCSO). Their MD director published this memo back in 2006. See attachment.

It seems to pertain to late entries and addendum.
Attachments
First Coast Medicare - Note.pdf
(72.88 KiB) Downloaded 207 times
Bill Wong, CHC, CHPC, CCS, CPC, CPMA, CDEO
AHIMA Approved ICD-10-CM/PCS Trainer
Compliance Analyst
bill.wong
Posts: 32
Joined: Wed Aug 17, 2016 6:02 pm

Fri Apr 28, 2017 12:12 pm

In addition, Noridian, our carrier, presented this webinar back in March/April 2016.

This is an excerpt from p.62 of the attachment,

Documentation Doesn’t Support Level Billed
•Each encounter must tell a complete story
•Prior encounters cannot be considered unless referenced by date in the encounter being audited


So, although it doesn't explicitly state "Notes must stand alone," it does come close.
Attachments
Common+E&M+Errors+by+Cert+and+Medical+Review+Presentation.pdf
(912.39 KiB) Downloaded 1433 times
Bill Wong, CHC, CHPC, CCS, CPC, CPMA, CDEO
AHIMA Approved ICD-10-CM/PCS Trainer
Compliance Analyst
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