Wiki Addendum - added to a medical record

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Sorry to disagree but if there is pertinent information, an addendum should be attached to the record. An addendum can be made providing it is a reasonable length of time for the situation. I have seen them added several months later and ask the provider how they could remember - it is usually a memorable event that they do not forget.
 
If it changes the information the claim reflected then it cannot be done as the claim then contains incorrect information. You must be very careful about allowing addendums after the claim is submitted. If the record is incomplete then the claim should be held until all information is documented.
 
mitchellde said:
If it changes the information the claim reflected then it cannot be done as the claim then contains incorrect information. You must be very careful about allowing addendums after the claim is submitted. If the record is incomplete then the claim should be held until all information is documented.
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Actually if the addendum changes the character of the claim, then a corrected claim needs to be resubmitted with a copy of the notes showing the reason for the resubmission. We would all hope that all information is in place before a claim is submitted, but there are cases where additional information becomes available after the fact.
 
This is a bad practice and it can look as though documentation is being adjusted for a payment decision. Once payment is made that is it. That is why it needs to be done prior to the claim being submitted. The coder should be reviewing the documentation before the claim is completed and most if not all incomplete documentation can be caught in this manner.
 
mitchellde said:
This is a bad practice and it can look as though documentation is being adjusted for a payment decision. Once payment is made that is it. That is why it needs to be done prior to the claim being submitted. The coder should be reviewing the documentation before the claim is completed and most if not all incomplete documentation can be caught in this manner.
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Of course it should not be happening on a large number of claims. But even the insurance companies come back and adjust claims after the fact. Coders may not know what the doctor forgot to include in the documentation. Thankfully we do have processes in place to make corrections.
 
Everyone here seems to be in the 'perfect world'. As coders, if we could be in every exam then everything might be perfect but that does not happen and situations occur to make addendums. The only one's that should be allowed are the ones that are important enough to be in the patient record. If that changes what should have been billed - then so be it and that has to be taken care of from the billing perspective.

To even think the coder should have known is ridiculous as we only understand what is in the record, if we see the record at all before billing.

Therefore my advice is to make any addendum whenever necessary providing the Provider is completely sure of the situation. If an addendum is coming at the point of an audit, then be very careful as this could be seen as manipulative. If there are frequent addendums by a provider, there is a situation where the provider probably needs a little training as this should not happen.

Hopefully we are here to manage the patient's healthcare and an addendum is necessary when the provider feels it is, etc.
 
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