Wiki Can medical coders make addendums?

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mrsrobinson525

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I work in a practice where providers code their own charts and I review them before processing. Some of the providers feel I should make chart addendums/late entries on their behalf. I don't think I can do this because I'm not a clinical staff member and I wasn't present at the time of the visit. Does anyone have experience with this? I'd like to bring some reference material to them on this subject.
Thanks so much!
 
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What kinds of addendums are they asking you to make to the charts? If it's anything to do with documentation, that is way beyond the scope of practice for a coder. I have a manager as well as a provider (different person) who once asked me to make a Date of Service change to an Op Note and when I told them that was out of my scope of practice and that I didn't feel comfortable doing it, the manager made the change himself.
 
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I think you know the answer, just need something in writing. No, coders cannot document. I'm aware of a company that went from charts to an EMR, and the EMR initially allowed the coders to document. The coding manager found out, went to the IT department and changed their access to coders could not update in the medical record. They were adding NDC numbers and other things that the clinical staff were missing. Big no, no.
 
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I think we would need to know what you mean, specifically, when you state, "make chart addendums/late entries". Are you talking about actual medical record documentation or are you talking about the work of a coder where you would correct/update the coding/billing according to the documentation in the medical record? Depending on this answer, you would want to take this question to your manager, director, or compliance department.

Some resources for you:

For medical review purposes, Medicare requires that services provided/ordered/certified be authenticated by the persons responsible for the care of the beneficiary in accordance with Medicare’s policies.

Falsified Documentation​

Providers are reminded that deliberate falsification of medical records is a felony offense and is viewed seriously when encountered. Examples of falsifying records include:
  • Creation of new records when records are requested
  • Back-dating entries
  • Post-dating entries
  • Pre-dating entries
  • Writing over, or
  • Adding to existing documentation (except as described in late entries, addendums and corrections)
Corrections to the medical record legally amended prior to claims submission and/or medical review will be considered in determining the validity of services billed. If these changes appear in the record following payment determination based on medical review, only the original record will be reviewed in determining payment of services billed to Medicare.

Appeal of claims denied on the basis of an incomplete record may result in a reversal of the original denial if the information supplied includes pages or components that were part of the original medical record, but were not submitted on the initial review.
 
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