Can you create an addendum to a locked encounter? This is how we handle this problem. That way you're not overriding the original documentation without noting it's an addendum.
If the ICD-9 code in the documentation is incorrect, we absolutely ask for an addendum. If the CPT code, either LOS or procedure was incorrectly reported, that won't change the documentation, so we give an FYI to the provider, make a note in our billing system, and correct the code. Our notes say something like "Per audit by Mary Jones, Level of service meets 99214, changed on 7/28/2011 from 99215 and billed"
Or, if they report a 17000 and it should have been 17010, we note, "per audit by Mary Jones, procedure is documented as...."
check out this link for help with ammending a 'closed' medical record. http://campus.ahima.org/audio/2007/RB080907.pdf
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