Wiki Addendums to documentation

[kimberliterpstra]

I have a provider that is asking me to give him a notification when certain items are lacking from his documentation, that would change his CPT coding. It is his opinion that if I give him the "heads up," he can go back and make an addendum for the missing or lacking information, then he can potentially charge for higher levels of care.

For example, when he wants to charge a consultation, sometimes the referring provider is missing from his note (he does work with residents, so the resident is not always putting this in the note)... the note will read "emergency room" or critical care team vs. the individual provider's name.

Another example, when he bills for critical care, the number of minutes is missing from the note...as it is time-based, it needs the number of minutes and the documentation needs to reflect critical care was administered.

My question is, is there a time limit as to when this addendum must be done? Does it need to be within a certain time period of seeing the patient?

I appreciate your input!

 

[Pam Warren]

There are no clear limitations other than filing limits (per payer) as to when addendums can take place prior to the claim going out the door. Pre-billing audits such as you are doing can be helpful to assist the provider in meeting requirements for certain kinds of visits, but you may want to caution your provider that adding an extra ROS or exam component to meet the number of bullets necessary to bill a higher level of service may not be medically necessary.

Your examples....missing referring provider, missing critical care time documentation, are all things we'd query prior to claim drop when doing a pre-bill audit and are reasons to add additional information. Missing diagnostic results, incomplete procedure notes, etc are all information that you would want to wait for. The challenge becomes when the provider starts to rely heavily on your guidance, and can't get a claim out the door without your involvement.

Our organization has a 72-hour turnaround for EHR completion in the office setting and a 30 day requriement for documentation completion in the facility setting. You may want to set similar standards (unless your practice is Joint Commission surveyable) so that your providers can become more self-sufficient.

 

[Rajesh1]

Addedndum

There are no clear limitations other than filing limits (per payer) as to when addendums can take place prior to the claim going out the door. Pre-billing audits such as you are doing can be helpful to assist the provider in meeting requirements for certain kinds of visits, but you may want to caution your provider that adding an extra ROS or exam component to meet the number of bullets necessary to bill a higher level of service may not be medically necessary.

Your examples....missing referring provider, missing critical care time documentation, are all things we'd query prior to claim drop when doing a pre-bill audit and are reasons to add additional information. Missing diagnostic results, incomplete procedure notes, etc are all information that you would want to wait for. The challenge becomes when the provider starts to rely heavily on your guidance, and can't get a claim out the door without your involvement.

Our organization has a 72-hour turnaround for EHR completion in the office setting and a 30 day requriement for documentation completion in the facility setting. You may want to set similar standards (unless your practice is Joint Commission surveyable) so that your providers can become more self-sufficient.

Great efforts Brooks!!!!!!