Progress notes

I have a question regarding progress notes. I have a doctor who doesn't feel that each progress note should stand alone. He used an ICD-9 code that was not supported in one of his notes but felt that because this was a follow up appt that he can refer back to another prior visit where the dx code was supported. He did not mention in his notes to "refer back to a previous note dated"... If there is a rule that each and every encounter should stand alone where would I find the information to confirm this? I have tried CMS and other sites.

Thanks,
JB

Common sense is the rule

that says you cannot include a diagnosis code that is not addressed anywhere in the note. At least HTN- CPM, or DM - stable.

Progress notes

I agree it is common sense. However this provider coded for inflamed SK but his notes only stated SK. In the pts visit prior to this one documentation supported the inflamed SK. If the provider had referred back to the prior visit, eg; "see prior notes dated 1-1-09", then I could allow the dx of inflamed SK. I'm I totally off or is this correct? Is there documentation out there somewhere to show the provider??

Progress notes

[I agree it is common sense. However this provider coded for inflamed SK but his notes only stated SK. In the pts visit prior to this one documentation supported the inflamed SK. If the provider had referred back to the prior visit, eg; "see prior notes dated 1-1-09", then I could of allowed the dx of inflamed SK. Am I totally off or is this correct? Is there documentation out there somewhere to show the provider?? ]

Progress notes

I think it's okay to use the diagnosis of inflamed in your example.

Progress notes

First off this was an office visit. Pt had an inflamed SK and it was treated by freezing, dx for that encounter was 702.11 and notes supported that. Pt returns two weeks later and the SK has not fallen off so the provider re-freezes it, notes do not state the SK is inflamed....but, because this was a follow up appt the provider felt you should just "assume" the dx of inflamed SK. I feel this is wrong, and that he would have to mention in his notes to refer back to a previous date to use 702.11 for the second visit. I thought if it's not documented...it didn't happen.

Progress notes

Is the payer questioning it, or are you?

If the payer, then just submit the previous notes that support the diagnosis.

It is true that each note should support the diagnosis, and that diagnosis codes should be at the highest level of specificity. Of course. But, is there a reason to question this? Does it really make a difference from a compliance perspective? Is the provider being paid for something that wasn't done?

So I got to thinking...

After you added your response that if the doc evaluated an irritated keratosis on one visit and decided it needed excision, then on the next visit she could write the procedure note and do the procedure and code it based on the finding of the previous visit and it would be appropriate. Although an operative note should have the diagnosis but that really applies to hospital procedures and is a hospital rule not a coding rule.

Progress notes

The Documentation Guidelines, in the beginning under General Principles, say what needs to be documented for an encounter.

I frequently find that the diagnosis codes for hospital services are not a perfect match with the documentation.