Wiki Addendums to ROS and physical exam

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Yes, providers may amend documentation for omissions or corrections, whether ROS, exam or any other documentation. There are specific requirements for amendments in the CMS claims processing manual. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/pim83c03.pdf section 3.3.2.5
The potential issues with amendments is if they appear to be created simply to justify a higher level of service. That would be fraud. But if the day after the visit, the physician is looking over a patient's note and he/she realizes they performed a cardiovascular exam and forgot to check it off in their EMR, they may do so as long as it is clear it is an amendment.
 
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csperoni said:
Yes, providers may amend documentation for omissions or corrections, whether ROS, exam or any other documentation. There are specific requirements for amendments in the CMS claims processing manual. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/pim83c03.pdf section 3.3.2.5
The potential issues with amendments is if they appear to be created simply to justify a higher level of service. That would be fraud. But if the day after the visit, the physician is looking over a patient's note and he/she realizes they performed a cardiovascular exam and forgot to check it off in their EMR, they may do so as long as it is clear it is an amendment.
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Thank you, I will look at the link. This is very helpful.
 
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