Coding from office visit notes prior to Inpatient admission

littlebit_62703@yahoo.com

Hello, 
I was told that coders are allowed to code from office visit notes that are within the 30 days from admission as long as it pertains to the admission? Does anyone know what reference this is coming from or has encountered this? Is this correct?  In all my years I have never seen or heard of this.  I have researched this and it does not coincide with Coding Clinic 3rd Quarter 2013 but the facility insists the coders can... I thought I saw another discussion on this on here awhile back but I cannot find it. Other than the coding clinic I referenced, I was looking for official source. Any thoughts or expertise in this situation would be greatly appreciated. 

Thanks

evanspx@sutterhealth.org

Search this website for 'use of prior data'...there are some very detailed discussions with citations.  And, "No"...one may not code from office visits within 30 days to my knowledge, either.  I'd ask the staff for the citation, chapter, verse, etc.

Resource: Review white paper recommendations on use of prior information in query creation

... in assessing information in the medical record from prior treatments. Codes cannot be assigned based on previous conditions. ... in assessing information in the medical record from prior treatments. Codes cannot be assigned based on previous conditions. ... “is so much more accessible” due to extensive use of electronic health records than it was in the past, ACDIS Director

Paul Evans, CCDS

morris-jeff@CooperHealth.edu

Short answer in no!

Hope they provide you with some evidence to back what they are saying...please share when they do. 

Jeff

evanspx@sutterhealth.org

Perhaps referencing acceptance of "interval H&P' that "may' completed up to 30 days PTA, and used if updated and accepted as part of the admission? (Certain Restrictions per JCAHO).

 Other than that, have never had of this concept.  Please advise if authoritative source provided?

littlebit_62703@yahoo.com

thank you all for your help. if they provide an a reference I will let you know but I have found one ...