Wiki Addendum question

[suela923@aol.com]

Hello!

I have a doctor who instead of dictating his addendum to his actual dictation, added it as a note to the chart. Is this sufficient documentation to bill for the addendum item?

Thank you,
Sue

 

[SheliaHill]

Sue,

In my experiences with audits, it is pertinent to have addendum documentation, as part of the original dictation; however, all auditors are different and remember one of the most important coding rules, not documented not done. Auditors do not like to search head to toe to find supporting documentation. Make it easy and supportive for auditors to not question documentation. All in one note, physician education is the key, when applicable to documentation of/for services rendered.

Good Luck!

 

[OCD_coder]

A provider can certainly write in a correction to the documentation to clarify information, it should never be used to meet a higher level of service than was provided.

For paper medical records:

-Making corrections, in keeping with these principles, generally entails using a single line strike-through (like this) so the original content is still legible.

-The author of the alteration must sign and date the revision.

-Amendments or delayed entries must also be signed and dated by the author upon entry.

http://www.cgsmedicare.com/parta/pubs/news/2012/1212/cope20874.html
http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R442PI.pdf