That doesn't mean that they can add details that didn't really exist before the claim denial; if the doctor does have a basis for adding a Dx to a note (after the claim denied), it had better be a good reason - that comes with explaination. A doctor that habitually leaves important details out of documentation should be informed of the risks that they are taking; a payer audit, or worse - an RAC audit , could lead to tens of thousands of dollars in refunded payments, fines, and possibly their ability to participate with Medicare/Medicaid. Willful neglect is viewed as harshly as fraud. Tread lightly, and remember; you code for accuracy of the visit, not for payment. The doctor has to follow the same rules with his/her documentation.
Okay, I'll get off my soapbox now...
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