"Notes must stand alone"
Moderators: Shannon DeConda, NAMAS Moderator
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.
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.
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
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- First Coast Medicare - Note.pdf
- (72.88 KiB) Downloaded 220 times
Bill Wong, CHC, CHPC, CCS, CPC, CPMA, CDEO
AHIMA Approved ICD-10-CM/PCS Trainer
Compliance Analyst
AHIMA Approved ICD-10-CM/PCS Trainer
Compliance Analyst
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.
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 1472 times
Bill Wong, CHC, CHPC, CCS, CPC, CPMA, CDEO
AHIMA Approved ICD-10-CM/PCS Trainer
Compliance Analyst
AHIMA Approved ICD-10-CM/PCS Trainer
Compliance Analyst