Is there a guideline or rule that indicates that you should only use the medical record documentation for that specific visit/admission for diagnosis coding purposes? Does each visit or admission stand alone? Would the coder go back to previous encounter records to assist in the coding of a current visit or admission?
Documentation for the current encounter should clearly reflect those diagnoses that are current and relevant for that encounter.
Conditions documented on previous encounters may not be clinically relevant on the current encounter. The physician is responsible for diagnosing and documenting all relevant conditions. A patient’s historical problem list is not necessarily the same for every encounter/visit. It is the physician’s responsibility to determine the diagnoses applicable to the current encounter and document in the patient’s record. When reporting recurring conditions and the recurring condition is still valid for the outpatient encounter or inpatient admission, recurring condition should be documented in the medical record with each encounter/admission. However, if the condition is not documented in the current health record, it would be inappropriate to go back to previous encounters to retrieve a diagnosis without physician confirmation.
This is an area where coders and/or department managers may need to educate physicians and/or practice managers on the need to include complete diagnoses when outpatient services are ordered and to continue to document chronic or longstanding conditions on each admission/encounter record.
Please note this advice applies to both ICD-9-CM and ICD-10-CM.