tci Part B Insider - 2008 Issue 19

DOCUMENTATION: Documentation Addendums Are Acceptable--Most of the Time

Ensure that the physician isn't amending the record just to get the claim paidImagine this: Your physician documents a visit with a patient but leaves out critical information about the services that the doctor provided. Now you-re unable to report the appropriate code for the visit.How can you remedy this? In many cases, the doctor can simply write an addendum to the medical record--but be sure that your addendum meets the requirements.Ensure clarity: -The critical issue when amending a patient's medical record is that the physician needs to ensure that any subsequent treating provider reviewing the patient's...

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