Ask for (and Get) Documentation Addenda

Know when it’s a G.O.O.D. idea, and how to do it properly.

by Erin Andersen, CPC, CHC

As a coder, you are responsible for assigning codes to services supported by documentation. You also have a responsibility to look for what isn’t in the documentation. When evaluating a provider’s encounter notes, ask yourself:

  • Is there contradictory information?
  • Given what I know of this procedure, does the information make sense?
  • Given what I know of this provider, do I think there is missing or incorrect information?

Electronic health records (EHRs) give clinicians the opportunity to use templates, dot phrases, smart sets, and copy and paste functions to bring in large blocks of information within seconds. Although this can save time, it also can compromise the integrity of the document if the provider does not edit the record carefully.

This raises an important question: When there isn’t enough information in the record to select a code, or you suspect there is missing or incorrect information, is it appropriate to seek an addendum from the provider? I have a process you can use to determine if an addendum is a G.O.O.D. idea.

Gather

To know if there is missing or incorrect information, you’ll need to know some facts about the provider’s process. Meet with the provider and ask him or her to walk you through a typical patient encounter. For instance,  ask the provider to describe a typical clinic visit; or, more simply, ask, “What are the steps you usually take when you perform that surgery?”

You may ask or be invited to shadow the provider for a morning to get a feel for his or her routine. Providers are often enthusiastic to show you what they do. They realize having you understand their work may help them maximize revenue with appropriate billing. Whether you meet with or shadow a provider, note all of what you learn so you can reference it later. I keep files on all my providers.

Opportunity

Once you have met, and possibly shadowed, your provider, scrutinize the documentation again. Is the provider doing work that isn’t being captured in the notes? Is the provider not doing work that is being captured in the notes? After you compile a list of questions, meet with the provider again to discuss them. Example questions may include:

“I see that you included a comprehensive past medical, surgical, family, and social history in your subsequent hospital visit note. From our previous conversation, it sounds like you typically do not discuss this information at subsequent visits. Was this information brought in as part of your template for diary purposes?”

“In looking at your procedure report, I do not see that you used ultrasound guidance. But when I shadowed you, I remember you often used it. Did you use it this time? If so, the primary procedure code allows you to bill separately for the guidance.”

“When we met a few weeks ago, you explained that you almost always do a record review before meeting with a new patient. I do not see that a record review summary was documented for this patient. Did you perform a record review for this patient?”

Be careful to ask questions respectfully, with the intent of seeking to clarify what is documented. Taking an accusatory tone will shut down the healthy dialogue you have going. Your provider will likely become defensive and all future interactions could be difficult or strained.

Option

Once you have the answers to your questions, decide if it is appropriate to addend the documentation. Your decision will depend on how long ago the date of service was from when your provider would addend. Much hinges on how clear your provider’s recollection is of the encounter.

In general, insurance companies frown on addenda completed weeks or months after the date of service because the validity of the information could be called into question. If the provider has very clear recall of that specific encounter, however, and the intent is to correct inaccurate information, an addendum for the note is recommended.

Document

If you identify missing or inaccurate information, and determine that it’s appropriate for the provider to addend, ask your provider if he or she is willing to addend to make the record correct. If you have an EHR, the system will automatically stamp the date, time, and author of the addendum.

It’s important to addend the specific encounter in question because the two notes will not be linked, nullifying the intention to correct the original note. For handwritten notes, the addendum should be placed as close to the original note as possible so the information can be found easily. The provider should:

  • Date the note he or she is addending;
  • State the original date of service;
  • Document the new information; and
  • Sign the addendum.

If appropriate, the provider may line through (once!) incorrect information in the new note, with his or her initials and the date next to the line-through. The addendum should contain the factual information that was omitted or inaccurately reported in the original note. If the new information contradicts the old information, a brief statement of explanation may be warranted.

Example 1: One of my provider’s forgot to include record review information is his new patient clinic note. I suggested that he add a statement like so: “I performed a record review prior to my visit with the patient. Pertinent details include …” This information could now be used to select the appropriate level evaluation and management (E/M) code.

Example 2: A provider stated in his review of systems that the patient had not lost any weight, but in looking at the patient’s questionnaire, the patient reported recently losing 10 lbs. When transferring the data from the questionnaire to the EHR, he accidentally left the default answer under Constitutional as “no weight loss.” Because of the potential for continued errors and the inefficiency of his process, I suggested that he review the questionnaire, reference it, and have it scanned into the EHR. I asked him to addend his note to correct the information: “Correction: I erroneously reported that the patient has not lost any weight. She, in fact, has lost 10 lbs. Please see the scanned questionnaire.”

Time Invested Pays Off

Don’t be concerned about how to balance the addenda process with maintaining your productivity quotas. Any effort you put into gathering information about your provider’s process, and educating him or her about documentation rules, will save you time (and your provider money) down the road. Your provider will see that you are invested in helping the practice maximize reimbursement by improving documentation, and he or she will respond in a timely fashion out of respect for what you do. Over time, you will have to request fewer addenda, and your provider’s documentation will be much easier to code. And that, my fellow coders, is priceless!

Erin Andersen, CPC, CHC, is a compliance specialist at Oregon Health and Science University in Portland, Ore. She has over 10 years of coding experience. Andersen serves as president for the Rose City Chapter and is the Region 8 representative for the AAPCCA board of directors.

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Renee Dustman

Renee Dustman

Renee Dustman is executive editor at AAPC. She has a Bachelor of Science degree in Journalism and a long history of writing just about anything for just about every kind of publication there is or ever has been. She’s also worked in production management for print media, and continues to dabble in graphic design.
Renee Dustman

About Has 425 Posts

Renee Dustman is executive editor at AAPC. She has a Bachelor of Science degree in Journalism and a long history of writing just about anything for just about every kind of publication there is or ever has been. She’s also worked in production management for print media, and continues to dabble in graphic design.

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