When I see or her of providers that want to fit their documentation to satisfy certain codes, I get concerned about the intent and purpose of their documentation. The role of a coder is not to lead the providers in their coding, but supply coding guidelines and regulations when it comes to coding. There is a tendency, and this is especially true in EHRs, to have bloated documentation just to hit certain E/M level criteria. This generally does not support medical necessity, and as you read the CMS E/M guidelines, you will find that medical necessity will always trump any audit tool or point system.
If the physician truly forgot to include additional information that was occuring during the time of service, then he/she can amend the documentation. Depending on the patient's payer, they might have different timeline rules, but the general rule of thumb is to amend ASAP, with proper attestation and reason for the amendment. Otherwise the amendment might come into question when the record is audited by CMS or the payer.
Hope this helps you!
CMS E/M guidelines
