TMacFarlane
Contributor
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 anywhere that states we can do any of the below as a CPC? (below is from Medicare)
Situation: I'm removing alot of 90833/90836 from E/M med mgmt visits and it's because its "n" on our template that says "pyschotherapy conducted". We have "at least 16 minutes", a psych note matching the appointment date to separate from the E/M portion - but the simple "n" removes the code and I just want to change it to "y". Same thing with our interactive complexity "y" vs. 'n'. Interpreter used but they put "n" so I can't add the code to bill it since it says "n".
We also have missing telehealth disclosures "telehealth conducted in home via" etc....we know it was telehealth - can CPC addendum non-clinical data?
Late Entry: A late entry supplies additional information that was omitted from the original entry. The late entry bears the current date, is added as soon as possible, is written only if the person documenting has total recall of the omitted information and signs the late entry.
Example: A late entry following treatment of multiple trauma might add: "The left foot was noted to be abraded laterally. John Doe MD 06/15/09"
Addendum: An addendum is used to provide information that was not available at the time of the original entry. The addendum should also be timely and bear the current date and reason for the addition or clarification of information being added to the medical record and be signed by the person making the addendum.
Example: An addendum could note: "The chest x-ray report was reviewed and showed an enlarged cardiac silhouette. John Doe MD 06/15/09"
Correction: When making a correction to the medical record, never write over, or otherwise obliterate the passage when an entry to a medical record is made in error. Draw a single line through the erroneous information, keeping the original entry legible. Sign or initial and date the deletion, stating the reason for correction above or in the margin. Document the correct information on the next line or space with the current date and time, making reference back to the original entry.
Correction of electronic records should follow the same principles of tracking both the original entry and the correction with the current date, time, reason for the change and initials of person making the correction. When a hard copy is generated from an electronic record, both records must show the correction. Any corrected record submitted must make clear the specific change made, the date of the change, and the identity of the person making that entry.
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 anywhere that states we can do any of the below as a CPC? (below is from Medicare)
Situation: I'm removing alot of 90833/90836 from E/M med mgmt visits and it's because its "n" on our template that says "pyschotherapy conducted". We have "at least 16 minutes", a psych note matching the appointment date to separate from the E/M portion - but the simple "n" removes the code and I just want to change it to "y". Same thing with our interactive complexity "y" vs. 'n'. Interpreter used but they put "n" so I can't add the code to bill it since it says "n".
We also have missing telehealth disclosures "telehealth conducted in home via" etc....we know it was telehealth - can CPC addendum non-clinical data?
Amended Medical Records
Late entries, addendums, or corrections to a medical record are legitimate occurrences in documentation of clinical services. A late entry, an addendum or a correction to the medical record, bears the current date of that entry and is signed by the person making the addition or change.Late Entry: A late entry supplies additional information that was omitted from the original entry. The late entry bears the current date, is added as soon as possible, is written only if the person documenting has total recall of the omitted information and signs the late entry.
Example: A late entry following treatment of multiple trauma might add: "The left foot was noted to be abraded laterally. John Doe MD 06/15/09"
Addendum: An addendum is used to provide information that was not available at the time of the original entry. The addendum should also be timely and bear the current date and reason for the addition or clarification of information being added to the medical record and be signed by the person making the addendum.
Example: An addendum could note: "The chest x-ray report was reviewed and showed an enlarged cardiac silhouette. John Doe MD 06/15/09"
Correction: When making a correction to the medical record, never write over, or otherwise obliterate the passage when an entry to a medical record is made in error. Draw a single line through the erroneous information, keeping the original entry legible. Sign or initial and date the deletion, stating the reason for correction above or in the margin. Document the correct information on the next line or space with the current date and time, making reference back to the original entry.
Correction of electronic records should follow the same principles of tracking both the original entry and the correction with the current date, time, reason for the change and initials of person making the correction. When a hard copy is generated from an electronic record, both records must show the correction. Any corrected record submitted must make clear the specific change made, the date of the change, and the identity of the person making that entry.