tci Medicare Compliance & Reimbursement - 2008 Issue 22

Documentation: Record Addendums Acceptable -- Most Of The Time

Ensure that the physician isn't amending the record just to get the claim paid Imagine 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...

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