tci Outpatient Facility Coding Alert - 2013 Issue 2

Documentation: Verify That Your Record Amendments Meet New CMS Guidelines

Heads up: Single-line corrections are fine. No practice -- or physician -- is immune to documentation that needs to be updated. Maybe the physician left out an important piece of information, such as the amount of time spent counseling the patient, or the patient’s diagnosis. When records need to be amended, be sure your practice follows the latest CMS rules, which were revised on Dec. 7, 2012, in Transmittal 442. In the transmittal, CMS encourages providers to "enter all relevant documents and entries" into the record at the time of service. However, CMS also acknowledges that "occasionally, upon...

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