tci General Surgery Coding Alert - 2020 Issue Q2

Reader Question: Exercise Caution When Changing Documentation

Question: When we see that documentation doesn’t match a code choice, we usually go back to the physician with questions, and sometimes they’ll acquiesce, agreeing that a lower-level code should be submitted on the claim. But other times the doctor will want to add additional documentation so the chart matches the code he wants to bill. Is this okay? SuperCoder Subscriber Answer: “Yes, a physician can go back and add an addendum to the record to correct/add additional information,” says Jennifer Lame, MPH, RHIT, a medical coding instructor with Southwest Wisconsin Technical College. Of course...

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