General Surgery Coding Alert

Question: 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, agreeing 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?

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Answer: “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.

Sign and date: One 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. That means physicians should initial or sign an addendum, and include the date and time they made the revision. 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.

Avoid: 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. The language used when discussing code changes with a provider can be important. A coder might say, “You usually perform an X in this situation and code XXXXX but I didn’t see it in the note. Could you review the note and see if it is complete?” rather than “If you add X to the note, we could bill XXXXX and get so much more reimbursement.”

Follow these steps to make sure your corrections will pass a review:

• If you are correcting an incorrect statement in the record, you should draw a single 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.
• Never try to make a late entry appear that it was there all along. Be sure to clearly mark the correction or supplementation as a late entry, including date and signature, with a title such as “Addendum to the medical record made on Jan 2, 2020, by Steve Smith, MD.”
• It’s a good idea to jot down the purpose of the entry. It’s also helpful to indicate the source of the additional information. Additions that are supported by information elsewhere in the record are most audit proof. This might be nursing notes, notes from another provider, something in the short op note, or elsewhere. The highest risk additions are E/M elements that suddenly raise the code level, such as 2 more elements of HPI or 1 more element of exam. Unless those elements can be found elsewhere in the record, you should avoid them.
• If you make a correction in the EHR and there was also a hard copy printed from the electronic record, you must also correct or reprint the hard copy.

Tip: Always review your payers’ addendum rules, especially federal health programs like Medicare and Medicaid.