Medicare Compliance & Reimbursement

Documentation clarifications can be a big help -- if you use them wisely. With the plethora of government entities poring over more and more of your patient records, it may be time to use a valuable weapon: documentation corrections and additions. But overuse of late entries may do more harm than good. This is a topic of greater concern given the number of entities that are now looking at Medicare claims, warns consultant Judy Adams in Chapel Hill, N.C. "And the scrutiny is just beginning!" "Record tampering undermines a clinician's credibility in the event of litigation," warns a guidebook on medical documentation by the University of North Texas. "It is important not to jeopardize the integrity of a patient's medical record by using a questionable correction method." Rumor: Some medical office staff believe they are not allowed to make corrections to a medical record if someone else (i.e., a supervisor) asks [...]