Amendement Guidelines

Hello,

I am having a disagreement with my supervisor as to whether or not a note can be amended after it has been signed. I say it can't because according to Medicare's guidelines, you cannot use an addendum to make guidelines.
The problem is when the date of service is dropped from the note. If the dictation shows that the physician signed it on 6/15, but then the printed note was sent over, missing the date, and the physician then made an amendment to the note adding the date of service, but it was done on 7/8, that would not be billable, correct?

Thanks in advance :)

re: Amendement Guidelines

An addendum is new documentation used to add information to an original entry. Addendums should be timely and bear the current date and reason for the additional information being added to the health record. Once a document has been final signed the only way to correct or revise documentation is to provide an addendum. The addendum should include a separate signature, date, and timed entry. the added information provides additional clinical information pertinent to the continuum of care.

An amendment is documentation meant to clarify health information within a health record. An amendment is made after the original documentation has been completed by the provider. All amendments should be timely and bear the current date of documentation. The organization should have a procedure that specifies how this process will be completed so that the integrity of the record remains intact and in compliance with documentation standards. In the case of amendments, the provider should re-sign the new report.

A correction is a change in the information meant to clarify inaccuracies after the original electronic document has been signed or rendered complete.