Wiki Altering Documentation

[arzola3]

Question...When reviewing documentation for HCC conditions. When a Doctor documents assessment and plan, he cannot go back and alter his documentation at a later date, I cannot find anything supporting this rule. Can anyone help me on where I can get something supporting this rule?

 

[ajudd]

Doctors can not go back to alter an office note. The best they could do is make an addendum and re-sign the note. This should not need to occur often.

If you're looking for HCC's and the note does not support a code that falls in an HCC category, you can't "adjust" not the note to fit what you need.
The doctor will just need to have better chart documentation practices going forward and know for that particular patient you're just out of luck

 

[MMAYCOCK]

Corrections are a legitimate occurance in documentation of clinical services

This is from CMS:

Amended Medical RecordsLate entries, addendums, or corrections to a medical record are legitimate occurrences in documentation of clinical services. A late entry, an addendum, or a correction to the medical record, bears the current date of that entry and is signed by the person making the addition or change.
When making a correction to the medical record, never write over, or otherwise obliterate the passage when an entry to a medical record is made in error. Draw a single line through the erroneous information, keeping the original entry legible. Sign and date the deletion, stating the reason for correction above or in the margin. Document the correct information on the next line or space with the current date and time, making reference back to the original entry.

Here is a link to a good detailed explanation of what types of corrections/amendments are appropriate.

https://www.noridianmedicare.com/provider/updates/docs/doc_Guides_amend_records_reprint.pdf?

 

[ajudd]

I did not mean to imply that corrections are not appropriate.

However, as an HCC coder myself - you must exercise extreme caution in "correcting" notes so that you are not appearing to be make a note fit an HCC catagory.
Medicare can, and does, audit submitted HCC's and you are required to send them documentation supporting the HCC submitted.

All I am saying, is addending a note is ok, but it should never be common practice and it should most certainly not exaggerate a patient's true issue just to make it fall into an HCC.

For example, do not diagnose impaired fasting BG as Diabetes because DM is an HCC and impaired fasting blood glucose is not covered.
The coder should also never make a leap in coding, either. If the patient has diabetes and chronic kidney disease, do not code to HCC 15 unless the physician has linked the CKD directly to the DM.

It's the coders name and credential on the line, and it's a lot of money at stake.