Created Aug 2019
Query
If a chronic condition is documented on a referral letter/form from an external provider (GP, another facility, WhiteCross, etc.) but nowhere else in the documentation for the episode of care, is this sufficient to assign the appropriate supplementary condition code from U78–U88?
Response
Documentation of a condition on a referral letter/form alone is insufficient for a code assignment. The condition must be documented within the current episode of admitted patient care.
Refer to ACS 0010 Clinical documentation and general abstraction and the ACCD Eleventh Edition FAQs – amended for further information and clarification.