tci General Surgery Coding Alert - 2013 Issue 6

Reader Question: Amend Documentation With Care

Question: One of our surgeon’s wants to amend documentation of a procedure, but we don’t know the correct way to do this without running into compliance issues. Can you recommend any resources? North Carolina Subscriber Answer: You can find CMS instruction for amending documentation in the Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.5 at www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/pim83c03.pdf. This section is titled “Amendments, Corrections and Delayed Entries in Medical Documentation.” CMS encourages providers to “enter all relevant documents and entries into the medical record at the time” of service. But...

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