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Wiki Documentation Question

absimpson721230

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Bolivia, NC
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One of our providers needs go back and add an approved dx for a test that was not included on the original dos documentation from 3 months ago. What are the guidelines for Medicare about changing documentation? Is there a time limit on going back and changing documentation? Our practices are located in NC/SC. Unable to locate a clear description on their website. Thank you!
 
While it is perfectly acceptable to add a late entry, addendum, or correction to the medical record, if the 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. This is why it is important for providers to review the diagnoses on their orders to ensure they are accurate and complete prior to the service being performed. Documentation Guidelines for Amended Records - JF Part B - Noridian (noridianmedicare.com)
 
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