Wiki Operative Note Addendum

[TnRushFan]

Does anyone know how long after the operation can the surgeon make an addendum to the operative note and it still be legal to bill?
I have a surgeon who operated on a patients left foot but documented right foot...he has added an addendum correcting the laterality. It has not yet been billed but is more than 30 days past the date of service [March DOS].

My colleague and I have a difference of opinion whether it is fraudulent / legal to bill?
Any thoughts or references are much appreciated...

 

[Pathos]

CMS has not come out and given us a specific time frame, the only guidelines I have seen are to make any amendments "timely" and "as soon as possible". The main issue here is integrity though; why was there a need to amend the notes? Can the provider fully recall what happened 30 days, or several months after the procedure?

CMS does specify some guidelines on what to include when making amendments:
Electronic Health Records (EHR): Medical record keeping within an EHR deserves special considerations; however, the principles specified above remain fundamental and necessary for document submission to MACs, CERT, Recovery Auditors, SMRC and ZPICs. Records sourced from electronic systems containing amendments, corrections or delayed entries must:

• a. Distinctly identify any amendment, correction or delayed entry, and
• b. Provide a reliable means to clearly identify the original content, the modified content, and the date and authorship of each modification of the record.

My local MAC cautions that if the intent was to falsify documentation, then those amendments are considered felony offenses.
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)

Sources:
Medicare Program Integrity Manual Chapter 3 - 3.3.2.5 - Amendments, Corrections and Delayed Entries in Medical Documentation
Noridian (MAC)

 

[CatchTheWind]

Our MAC (First Coast Service Options) also states:

“Medicare expects the documentation to be generated at the time of service or shortly thereafter. Delayed entries within a reasonable time frame (24-48 hrs.) are acceptable for purposes of clarification, error correction, the addition of information not initially available, and if certain unusual circumstances prevented the generation of the note at the time of service.”

“Delayed written explanations… serve for clarification only and cannot be used to add and authenticate services billed and not documented at the time of service or to retrospectively substantiate medical necessity. For that, the medical record must stand on its own with the original entry corroborating that the service was rendered and was medically necessary.”

However, those are guidelines. There is no rule that says you can't bill if you corrected an error later, as long as the amendment is properly signed and dated. I think what they are getting at that they don't want providers to get creative about adding amendments that tweak the details of the note or are used for justification of medical necessity.