Wiki Rules for MD changing documentation?

[heatherfrycpc]

I'm wondering if there's a rule or guideline giving a time frame for allowing providers to change or update their documentation.
Specifically, our docs forget to put discharge time or critical care time on their documentation. I personally feel like, there's no way they remember several days or sometimes weeks after the fact, how long they actually spent with a patient.

They are allowed to add addendums to document the time spent so we can bill accordingly but is this ok? Is there any rules on a time limit on this?

Thank you!!

 

[Chelle-Lynn]

You can bill for a service when an addendum has been placed, provided you adhere to the rules of affixing an addendum to your original documentation.

Late entries, addendums or corrections to a medical record are legitimate occurrences in documentation of clinical services. Noridian advises that when adding an addendum, be sure to:
1. Note the current date of the entry.
2. List the reason for the addition or clarification of information.
3. Have the person making the change add his signature to the record.
4. Add the entry as soon as possible.
5. Do not delete the original entry. Instead, mark a single line through the original entry, and insert the clarified information on the next line or space, also adding the current date and time.
6. Follow the same principles for an electronic medical record (EMR). If using a hard copy generated from an EMR, make sure both versions show the same updates.

Per Noridian, corrections to the medical record legally amended prior to claims submission and/or medical review will be considered in determining the validity of services billed. Be expedient about late additions or addendums because after a payment determination is made, contractors will consider the original medical record only if you added the information after the payment determination. However, if your claim is denied with the cause being an incomplete medical record and you have since made an addendum, you can present the additional information to overturn the denial

As far as how long is too long for an addendum? There is no set guidelines such as a timeframe (5 days, 10 days, etc). The definition is open to what the provider reasonably feels that they can truthfully document based on their recollection of the service. Summary...there is no written or implied rule of thumb on this matter. It is up to performing provider. Although it is recommended for the sake of audits, that there be a policy in place for how your office will handle this grey area so as to be consistent.