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Incident to documentation

  1. Default Incident to documentation
    Medical Coding Books
    I would like some advice on the following scenario:
    Patient was scheduled for a follow-up visit with an NP which was to be billed as an 'incidnet to' visit. During the visit the patient voice a new problem, the MD came into the room, examined and began the treatment plan for the new problem but forgot to document it in the patients record. The physician is asking if it be acceptable to make a late entry and document the exam and treatment plan. The patient was seen several weeks ago. Thanks

  2. #2
    Columbia, MO
    If the claim has been submitted it is too late. If not he may make an addemdum.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    Regardless if the claim has been submitted. The physician should make an addendum in the record to document the problem. He should not back date the note, but he should document it.

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