Medicare Compliance & Reimbursement

Documentation Red Flags: Know When A Clarification Hurts Instead of Helps "With regard to supplementing documentation in preparation for ... audits, providers certainly need to proceed with care," advises Washington, D.C.-based attorney Elizabeth Hogue. "Whether or not it is appropriate to supplement documentation must be decided on a case-by-case basis." You should not be routinely making revisions to clinical records prior to sending them off in response to an advance development request (ADR), counsels regulatory consultant Rebecca Friedman Zuber in Chicago, Ill. Red flag: If you make a lot of corrections in your clinical records, that will raise questions should your records be reviewed, Zuber warns. "It will look like they are writing what they want to have there, not documenting what actually occurred during the delivery of care." When correcting or adding to the medical record, "the greatest error of all is to write information just because someone told [...]