Wiki risk

[pennyd]

Here's a question we use an EMR and there are often times I do not agree with the code the physician selects and signs off on, once discussed and determined, if I need to change that code in my billing of that note, is there a risk with insurance audits if I do an addendum on these notes? Do I have to do an addendum? When we send out these chart requests the code does not show on the notes anyway. Could this be a potential problem?

 

[FTessaBartels]

You cannot ammend physician documentation

Forgive me if I misunderstand your post .... but No ... NO ... you cannot amend a physician's documentation for any reason whatsoever.

You may ask the physician to clarify / amend documentation if there is a question about the services performed/documented vs charge submitted. But you cannot actually alter the documentation.

Hope that helps.

F Tessa Bartels, CPC, CEMC