Forum - Questions & Answers

Feb 13th, 2013 - lyndaw

Addendums

I recently sat in a webinar for E/M documentation, we recieved a handbook with some great information in it. Can anyone elaborate and give some examples regarding the statement below. The first sentenance is what I'm questioning. For example if your coding and you notice the doctor did'nt document something in order to get the code you know it should be, this seems to state that you cant tell him and he can not correct it???? is that right???
Thanks in advance

"The addendum should address additional, clinically relevant information; not information just to meet regulatory
requirements or to later validate a CPT® code that was initially down coded due to lack of supporting documentation.
When making a correction to the medical record, legal requirements must be followed. Never write over, erase or
obliterate an entry to the medical record. A single line should be drawn through the incorrect information and the
correction should be written near the deletion. The incorrect information should still be legible. The practitioner should
sign and date the deletion. A correction can also be made by submitting the original record and adding the correction(s)
as an addendum, preferably typed, with a full explanation of why the record was in error. The practitioner should sign
and date the correction."

Feb 13th, 2013 - mom2mad 19 

re: Addendums

My interruptions of this statement are that addendums should not be done for the sole purpose of getting a denied claim to pay. Addendums should be done for the purpose of providing complete documentation for the medical record.
This is just my thoughts ?



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