tci ED Coding & Reimbursement Alert - 2006 Issue 3

READER QUESTIONS: Use Reason When Returning Charts

Question: What is the legality of returning charts to the physician to amend the documentation to reflect the appropriate E/M level and care she provided? I know this practice is standard, but are there any laws governing it?Kansas Subscriber Answer: Your first step in determining the legality of this practice should be to check with the policies of your hospital. Hospital policy will very likely give you information regarding the guidelines about signing and dating the late note and tell you how long after the patient encounter the physician can add the note.From a compliance perspective, if...

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