Physiacian Documentation


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Please help
Does anyone know of a resource that shows when it is ok to ask a physician to add documentation to a chart and when it is not because it may be mistaken as trying to get more revenue for the visit (upcoding). We have not been able to find anything in writting. Does anyone have anything they can share a copy of?
I might check (though it will be vague) the stated "Documentation Guidelines" relating to auditing EM--I think this is stated CMS standard. It won't give you the level of detail you're looking for, but a general idea.

Also, check with the professional physician association related to that speciality (e.g., American College of Radiology, American College of Emergency Physicians) for documentation guidelines. This should provide more specifics or benchmarks.

From all areas I've had contact with, it is acceptable to request an addendum to a record (as long as the physician is willing and providing that addendum) in order to further specify elements of the service provided.

Think coding ethics here: request addendums where you need more information to properly code a case. If you're just trying optimize reimbursement, that is more of a documentation improvement initiative and handled appropriately.

Hope this helps.
In Ohio, our local Medicare Carrier used to have a document that stated that addendums should be used to clarify patient care and not to add information for billing purposes. On those lines, when it comes to lack of documentation, we use the chart as a "teaching moment"; that is, what they could have billed IF they had documented appropriately.