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Thread: Incident to documentation

  1. #1

    Default Incident to documentation

    AAPC: Back to School
    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
    Join Date
    Apr 2007
    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
    Join Date
    Apr 2007


    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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