ED Coding and Reimbursement Alert

Determine when – and how – you should ask the physician to expand documentation.

When a coder receives a chart, there’s often a code circled at the top – but it’s the coder’s job to determine whether the documentation matches the code selection. And when it doesn’t, the question arises about whether more can be added when necessary.

A coder submitted a question to ED Coding Alert asking about that very situation. “When we see that documentation doesn’t match a code choice, we usually go back to the physician with questions, and sometimes they’ll acquiesce and agree that a lower-level code should be submitted on the claim. But other times the doctor will want to add additional documentation so the chart matches the code he wants to bill. Is this okay?”

To answer the coder’s question, we did a bit of scoping through CMS regulations. And as with all other coding situations, the answer will depend on several factors.

Addenda Are Legal

“Yes, a physician can go back and add an addendum to the record to correct/add additional information,” says Jennifer Lame, MPH, RHIT, a medical coding instructor with Southwest Wisconsin Technical College. Of course, you must stay within the regulations of your payer, state laws, hospital rules, and your own compliance program to do this. In addition, you must ensure that the physician isn’t amending the record just to get the claim paid.

Imagine this: Your physician documents a visit with a patient but leaves out critical information about the services that the doctor provided. Now you’re unable to report the appropriate code for the visit.

Ensure clarity: The critical issue when amending a patient’s medical record is that the physician needs to ensure that any subsequent treating provider reviewing the patient’s medical record can determine precisely what the amendment is and when it was made.

Make sure you’re amending for the right reasons: Your first question to the physician should be “Why are you addending it?”. You should never consider whether the patient has coverage when making your decision on how to treat the patient, and you can’t change the record to reflect information that will help get the claim paid if it’s not true to what the doctor performed.

Make Sure Addendum Is Signed, Dated

When you add information to the medical record, the physician should initial or sign the addendum, and include the date and time that he made the revision.

Keep in mind: The caregiver who performed the service should personally make the change to the record. The signature and date can’t be added by a representative or the coder.

EHR tip: If the physician is making entries on an electronic medical record, this approach may not be possible depending upon the software that is being utilized. Nevertheless, every effort possible should be made to link the revision to the incorrect entry.

Here’s How to Do It

As long as the doctor actually remembers the information, or reads notes or other written information that triggers his memory of the additional information, he can add information at any time. Follow these steps to make sure your corrections will pass a review:

1. Cross out old information rather than deleting it. If you are correcting an incorrect statement in the record, you should draw a line through the statement and put the word “error” next to it. Then sign or initial it (depending on your policy) and put the date. The original information must still be readable and included in the record. Use just a single line to cross it out.

2. Title the late entry. Never try to make a late entry appear like it was there all along. Be sure to clearly mark the correction or supplementation as a late entry with a title such as “Addendum to the medical record made on August 12, 2019, by Steve Smith, MD.”

3. Include signature and date. Any late entry should include its date, and corrections or additions to documentation should ideally be made by the documentation’s original author. That person should sign the correction as well as dating it.

4. Add the reason. It’s a good idea to jot down the purpose of the entry -- for example, clarification. It’s also helpful to indicate the source of the additional information, such as “based on notes jotted during the visit” or “addended note after listening to dictated report.”

5. Remember hard copies. If you make a correction in the electronic health record and there was also a hard copy printed from the electronic record, the hard copy must also be corrected.