addendum

  1. T

    Wiki Can CPC update basic documentation to bill codes?

    Quick question: If I need to change a "n" to a "y" or update simple things like typo's or character errors in typing. Can I use any of the below and re-sign the SOAP/documentation or does it have to be the provider? We obviously code CPT/DX based on documentation, but is there language...
  2. M

    Wiki Signing off

    I can't find any guidelines on this. Should providers wait for lab results before closing/signing off on the encounter? Example: If they order a Vit D lab because the patient is experiencing fatigue. The lab result comes back with a vit D deficiency. Does the provider change the fatigue...
  3. S

    Wiki What is the timeframe for a provider to complete or sign addendum?

    We have scribes. Provider reviews the notes and signs. If the scribe then makes an addendum to the note (example- additional procedure documentation) and sends back to Provider to review, date and sign off on the addendum, What is considered a reasonable time frame to complete this in order to...
  4. D

    Wiki Documentation - like an addendum

    Can we tell the physician what is missing in their HPI? Like if they are not meeting all the criteria can we tell them what is missing so they can meet it? If so, how do we know that the physician performed/gathered all the information? can they add it after the fact like an addendum?
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