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Wiki Rules and Regs requireing addendums to EMR chart notes

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barnetn1

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Puyallup, WA
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I work for a community health center that has implemented EMR full scale. We are now coming to the issue of coding compliance - when an addendum is required.

Does a chart note require an addendum if the doctor originally billed out a new patient code but saw an established patient?

Is an addendum required if the doctor sequenced the diagnosis wrong in the chart note?

Currently our process is - the doctor sends the charges directly out the door. But when denials are worked in the billing office these are the questions being asked.

Thank you,
Nicole Barnett
 
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