Wiki Adding detail to an op report

[wmcodylee]

We are having denials for Carpal Trap surgeries. We are billing 15736 for the fascioucutaneous flap and we are getting denials saying there isn't enough documentation to support that code. Can my doctor redictate his note to add specific details regarding the fascio flap even if the note is from a year ago. He is doing fascio flap during surgery and he does say it in the note, just not in great detail. The codes wont change, the only thing that will change is more detail to support the codes and the surgery being performed.

 

[CodingKing]

No, its way too late to amend notes. Note must be complete prior to claim submission.

This might be helpful when it comes to timeliness, for instance 24-48 hours is reasonable

https://www.aapc.com/blog/23844-medical-record-entry-timeliness-what-is-reasonable/

 

[wmcodylee]

No, its way too late to amend notes. Note must be complete prior to claim submission.

Thank you. That is what I thought, but wanted to make sure before I took this to my office manager. Can you point me in the direction of the guidelines for that?

 

[CodingKing]

The payer should have medical records standards that you could reference. I don't know of any payer that would accept amendment of records after an audit.