decisionhealth Newsletters, Part B News - 2015 Issue 3 (March)
Follow these 6 guidelines when making an addendum to the medical record
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Article Overview
This article addresses a physician documentation question about addendums to an operative report and summarizes general medical record correction practices discussed by a Part B contractor. It is relevant to coders, billers, compliance staff, and physician practices that need to understand how amended documentation is handled for claims submission and medical review. The discussion focuses on documentation integrity, timing, signatures, and record correction procedures rather than on code selection.
Why This Topic Matters
Accurate addendum handling can affect whether documentation supports billed services and whether revised records are considered during claims processing or appeal review. The topic is important for compliance, audit readiness, and maintaining consistent paper and electronic records.
What You Will Learn
- How addendums and late entries are generally handled in medical records
- What documentation elements are commonly expected when a record is corrected or clarified
- How amended documentation may be considered during claims submission and medical review
- Why timing and consistency between original and updated records matter
Who Should Read This
- Physician practices
- Medical coders
- Medical billers
- Compliance staff
- Health information management professionals
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