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addendum to operative notes

  1. #1
    Default addendum to operative notes
    Medical Coding Books
    Can anyone tell me if an addendum can be made to an operative note after the procedure is billed?
    Thank you

  2. #2
    Milwaukee WI
    Default Can be done vs Should be done
    It CAN be done. But it probably SHOULD NOT be done.

    Of course, this depends on what is the addendum for?

    Let's say that Primary Surgeon dictates his note, but fails to include Co-Surgeon on his op note. You bill out this surgery per the dictation.

    A few days after you've submitted a claim for this surgery, you get a call from Co-Surgeon's office asking about the code(s) to use for this surgery. You would ask Primary Surgeon to dictate an addendum to add the co-surgeon. You would also IMMEDIATELY send a corrected claim using the -62 modifier on Primary Surgeon's bill.

    That scenario is an example of a dictation problem, where the coder may not have had any idea there was something "wrong" with the dictation before it was coded and billed.

    On the other hand .... if the coder identifies that there is missing or confusing information on the operative report, it is best to wait for the addendum/correction to dictation BEFORE submitting a claim.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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