A provider’s documentation for a specific outpatient encounter states this and only this:
"After the patient was seen and examined, it was determined that there has been no change from the patient’s condition since the last H&P was completed. Agree with the note from 8/22/17."
The note from 8/22 that is referenced is from a different provider than the one making this statement.
It is my understanding that this would only be acceptable for an inpatient or surgical admission if the other H&P had been done within 30 days of the DOS. In any other setting, this type of documentation would be unacceptable and whatever was diagnosed and treated on 8/22 would not be able to be coded for this new DOS. Am I correct? I am sure there is a guideline somewhere, but I cannot find anything. Can anyone help me?
"After the patient was seen and examined, it was determined that there has been no change from the patient’s condition since the last H&P was completed. Agree with the note from 8/22/17."
The note from 8/22 that is referenced is from a different provider than the one making this statement.
It is my understanding that this would only be acceptable for an inpatient or surgical admission if the other H&P had been done within 30 days of the DOS. In any other setting, this type of documentation would be unacceptable and whatever was diagnosed and treated on 8/22 would not be able to be coded for this new DOS. Am I correct? I am sure there is a guideline somewhere, but I cannot find anything. Can anyone help me?