Wiki Documentation Error

[coder1]

Good Morning Coding World,

If a MA has provided service to a patient (was trying to help provider) and than provider sign the note but wasn't present. Should provider create addendum to the record indication that documentation was incorrect? is there any guidance available for this situation?


Thanks

 

[ccollison]

What do you mean by "the provider was not present"? In most states, a MA can not provide services without the supervision of a provider, PA, NP or physician. Meaning the provider must be in the office. If the MA's documentation was just in error, the provider could draw a line thru the incorrect entry and an addendum stating he is correcting an error and sign it. You could review Medicare supervision requirements as well as the requirements for erroneous entries.

C Collison CPC, CPPM, CPMA