"Notes must stand alone"

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"Notes must stand alone"

Postby JJones » Tue Mar 07, 2017 12:43 am

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.
JJones
 
Posts: 35
Joined: Sun Dec 21, 2014 2:32 am

Re: "Notes must stand alone"

Postby bill.wong » Sat Apr 22, 2017 5:15 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 154 times
Bill Wong, CHC, CHPC, CCS, CPC, CPMA, CDEO
AHIMA Approved ICD-10-CM/PCS Trainer
Sr. Coding & Compliance Educator/Auditor
bill.wong
 
Posts: 31
Joined: Wed Aug 17, 2016 10:02 pm

Re: "Notes must stand alone"

Postby bill.wong » Fri Apr 28, 2017 4:12 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 1268 times
Bill Wong, CHC, CHPC, CCS, CPC, CPMA, CDEO
AHIMA Approved ICD-10-CM/PCS Trainer
Sr. Coding & Compliance Educator/Auditor
bill.wong
 
Posts: 31
Joined: Wed Aug 17, 2016 10:02 pm


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