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Time limit to post an addendum...

  1. #1
    Default Time limit to post an addendum...
    Medical Coding Books
    Does anyone know if there is a time limit to post an addendum to a note? We use EMR. For example; a patient comes in for an office visit, the note was coded with a new patient visit; however the patient is an established patient and the wrong code was assigned. Now I need the physician to add an addendum to change the code but it has been 2-3 days since the physician electronically signed off on the note. Our system will let you reopen the note after 24 hours only to make corrections.

    Kristie Stokes, CPC, CPMA, CCS, CMDP, ICDCT-CM

    AAPCCA Board of Directors 2014-2017
    Region 1 - Northeast
    Maine, New Hampshire, Vermont, Massachusetts, Connecticut, Rhode Island, New York

    Today, give a stranger one of your smiles. It might be the only sunshine they see all day.

  2. #2
    Milwaukee WI
    Default I think you're fine
    I think you'd be fine to post an addendum in this time frame (2-3 days post signing).

    F Tessa Bartels, CPC, CEMC

  3. Default
    I use EMR. You would be falsifying your billing if you used a new patient E&M for an established patient, no matter how long after the charge was entered. I correct them months later.

  4. Default Addendums
    Could someone please provide CMS reference to time allowed for addendums - ie that clearly states 24 - 48 hours after service or reasonable recall. I have a physical exam addendum 12 days after the visit and I need a hard reference.

  5. #5
    THere is not a hard and fast rule published by CMS - some local Medicare Carriers will post their recommended timeframes (i.e. WPS used to have a recommended time frame of 24-48 hours). In the last month Coding Edge there was a good article about making addendums to notes with commentary from different lawyers.

    The other thing to take into consideration is the reason for the addendum. If it is solely for billing purposes I would discourage addendums that "add" information that is not clinically relevant on a frequent basis. If it is to add something that adds clinical significance to the note and is not specifically for billing purposes then you may have additional time.

    What will be looked at is the content of the addendum and could the detail and content of the addendum reasonably be rememberd in accuracy in the time between the service and the addendum. For example - if a provider is adding one thing he forgot to mention but the rest of the note is completed there may be a larger timeframe window but if nothing was documented and a Provider produces a note with incredible detail 60 days later there will be question as to the accuracy and credebility of the note.

    Bottom line - it is good to document at the time of service or as soon as possible after the service. If there is a late entry it should be dated and notated why the entry was late. If it is over a specified time we recommend the provider state "to the best of my recollection..." or something to that effect.

    As far as changing a new patient to established - an addendum shouldn't have to be made in the actual note - it would just need to be releveled acoording to the established level code element requirements.

    Sorry for the rambling - we have been discussing this on our compliance committee for the past year!
    Christina Musser, CPC

  6. #6
    Columbia, MO
    You cannot add or change information in the medical record that conflicts with the information submitted on the claim since it will then look as though the claim was falsely submitted.

    Debra A. Mitchell, MSPH, CPC-H

  7. #7
    New Windsor, New York
    Default Even in this case?
    Quote Originally Posted by mitchellde View Post
    You cannot add or change information in the medical record that conflicts with the information submitted on the claim since it will then look as though the claim was falsely submitted.
    From the original question, I thought that this would be a CORRECTION - the claim had incorrect information and the correct information was subsequently collected and submitted. In many cases, yes, that is correct, especially if it is resulting in changes "just to get it paid." But something like was done to PREVENT an incorrect payment, not to cover something up.


    Director, Health Information Management
    HealthAlliance of the Hudson Valley
    Kingston, NY

  8. #8
    Columbia, MO
    why would the note need to be amended in order to submit a corrected claim. The codes should not be in the medical record. So if the claim was submitted incorrectly then a corrected claim should be submitted. Yes that is fine, but what i do not understand is really 2 things, 1st why would the medical chart notes need to be amended and 2nd why was this not caught prior to the claim being submitted. Just a thought

    Debra A. Mitchell, MSPH, CPC-H

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