E/M Coding Alert - 2017 Issue 5
Reader Question: Can You Send Chart Back Asking for Missing Critical Care Time?
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Article Overview
This article addresses a documentation and compliance question in hospital and physician coding: whether charts may be returned for missing critical care time and how addenda are handled after coder review. It discusses general practice variation, the importance of organizational policy and compliance planning, and the timing considerations that may affect whether supplemental documentation is usable. The article is intended for coding, billing, compliance, and physician documentation staff seeking broad guidance on critical care recordkeeping.
Why This Topic Matters
Critical care documentation is highly sensitive to timing and record completeness, so even general guidance on addenda and chart review can affect compliance, audit readiness, and documentation workflows.
What You Will Learn
- How organizations may approach missing critical care time in chart review
- Why addenda timing and documentation memory matter in critical care records
- How compliance plans and coding policies influence documentation follow-up
- Why some groups use returned charts primarily for education
Who Should Read This
- Medical coders
- Coding auditors
- Compliance staff
- Physician documentation specialists
- Hospital billing staff
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