Wiki Addendum

[pcossentino]

Question to fellow AAPC billers. If your Doc is adding an Addendum to a visit note to correct a code what wording would he use? is there anything in particular he needs to write. Just say the EHR coded a Level 3 but he thinks the visit was a level 5. We wont bill it out as a level 5 unless he adds an addendum stating it is actually a level 5. Any advice is appreciated.
Priscllla

 

[CodingKing]

Doesn't matter what level he/she says it is. Physician would add what ever clinical information that was omitted.

 

[mitchellde]

It does not matter what the EHR suggests as a code. The code on the claim needs to match the documentation, the provider does not need to amend the record to explain this. EHR codes are just suggestions based on a programmed algorithm and key words. The code itself is not a medical record item that any future decisions will be based on. The documentation is what needs to be coded and this codes are the ones that are put on the claim.

 

[pcossentino]

Thank You!!

Fantastic, Thank You !