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Documentation Addendum

  1. #1
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    Greeley, Colorado
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    Default Documentation Addendum
    Medical Coding Books
    Does anyone know where I can find information about who can do an addendum to documentation? Specifically, can one provider do an addendum to another providers documentation?
    Lisa Bledsoe, CPC, CPMA

  2. #2
    Location
    Tacoma, WA
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    1,087
    Default
    Quote Originally Posted by Lisa Bledsoe View Post
    Does anyone know where I can find information about who can do an addendum to documentation? Specifically, can one provider do an addendum to another providers documentation?
    I found this on the HCPro website Q&A, it doesn't state that another provider can't add an addendum to documentation. I think as long as it is clear who the author is and why they are making the entry:

    "The American Health Information Management Association published practice guidelines that address late entries as follows:


    “Any clinical provider documenting within the health record may need to enter a late entry. The organization should clearly define how this process occurs within their system. Tracking and trending within the electronic record will be dependent on the system; the organization should clearly understand this process.

    “In addition, specific policies and procedures should guide clinical care providers on how to correctly make a late entry within the health record. The author should document within the entry that it is a late entry.

    “Typically late entries apply to direct documentation only; for example, physician orders, progress notes or nursing assessments. Dictated reports such as history and physicals, although dictated outside of organizational time frames, would not be considered a late entry.

    “Note: Some systems may not have late entry functionality. The late entry is shown as an addendum.”

    The following is an example of one institution's policy regarding late entries:
    When a pertinent entry was missed or not written in a timely manner, the author must meet the following requirements:
    ■Identify the new entry as a “late entry.”
    ■Enter the current date and time – do not attempt to give the appearance that the entry was made on a previous date or an earlier time.
    ■The entry must be signed.
    ■Identify or refer to the date and circumstance for which the late entry or addendum is written.
    ■When making a late entry, document as soon as possible. There is no time limit for writing a late entry; however, the longer the time lapse, the less reliable the entry becomes.
    ■An addendum is another type of late entry that is used to provide additional information in conjunction with a previous entry.
    ■Document the date and time on which the addendum was made.
    ■Write “addendum” and state the reason for creating the addendum, referring back to the original entry.
    ■When writing an addendum, complete it as soon as possible after the original note.

    Editor's Note: This question was answered by Fran Jurcak, RN, MSN, CCDS, a manager with Wellspring + Stockamp, a division of Huron Healthcare in Chicago. Contact her at fjurcak@huronconsultinggroup.com."
    Arlene J. Smith, CPC, CPMA, CEMC, COBGC

  3. Default
    I agree. The author of the document needs to be the individual to do the addendum. In addition, we also need to consider the "incident to" rules if the documentation is in a office setting with a physician & PA or NP. In this case, there is the possibility where the documentation from both the providers can be considered as one provider providing the "incident to" guidelines are being followed.

  4. #4
    Location
    Greeley, Colorado
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    Default what about this scenario
    Patient is seen in the office on 11/9/11 for routine visit; ends up in ER on 11/15/11 and admitted by a physician of the same practice as seen on 11/9/11...for his H&P he uses the last office visit and writes a minimal addendum as to why the patient is now being admitted. I don't think this is appropriate for coding an initial inpatient visit...any other opinions? Anyone have links to support?
    Thanks!
    Lisa Bledsoe, CPC, CPMA

  5. #5
    Location
    Ellenville, New York
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    1,177
    Default A prior office visit might be able to be used
    I did agree with you, Lisa, that the prior office visit couldn't be used and that there had to be documentation of a current or admitting E/M service. However, while researching another question for our business office, I found this gem in the Medicare Claim Processing Manual, Chapter 12, section 30.6.9.1:

    "When a physician performs a visit that meets the definition of a Level 5 office visit several days prior to an admission and on the day of admission performs less than a comprehensive history and physical, he or she should report the office visit that reflects the services furnished and also report the lowest level initial hospital care code (i.e., code 99221) for the initial hospital admission. Contractors pay the office visit as billed and the Level 1 initial hospital care code."

    Now, it would be nice to have a definition of "several days" (IMO, your 6 day time frame would count as that for me), but in your scenario, if the visit on 11/9/11 was a 99215, then with this as my proof, I would assign 99221 for the 11/15/11 admission. But if the doc is looking to use these key elements to assign 99222 or 99223, then Houston, we have a problem.

    Lance Smith, MPA, COC, CPMA, CEMC, RHIT, CCS-P, CHC, CHPC

    Director, Health Information Management
    HealthAlliance of the Hudson Valley
    Kingston, NY


    2016 Secretary
    Ellenville, NY Local Chapter

  6. #6
    Location
    Greeley, Colorado
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    Quote Originally Posted by MnTwins29 View Post
    I did agree with you, Lisa, that the prior office visit couldn't be used and that there had to be documentation of a current or admitting E/M service. However, while researching another question for our business office, I found this gem in the Medicare Claim Processing Manual, Chapter 12, section 30.6.9.1:

    "When a physician performs a visit that meets the definition of a Level 5 office visit several days prior to an admission and on the day of admission performs less than a comprehensive history and physical, he or she should report the office visit that reflects the services furnished and also report the lowest level initial hospital care code (i.e., code 99221) for the initial hospital admission. Contractors pay the office visit as billed and the Level 1 initial hospital care code."

    Now, it would be nice to have a definition of "several days" (IMO, your 6 day time frame would count as that for me), but in your scenario, if the visit on 11/9/11 was a 99215, then with this as my proof, I would assign 99221 for the 11/15/11 admission. But if the doc is looking to use these key elements to assign 99222 or 99223, then Houston, we have a problem.

    Great info Lance! Thank you!
    Lisa Bledsoe, CPC, CPMA

  7. #7
    Location
    Greeley, Colorado
    Posts
    2,045
    Question
    Quote Originally Posted by MnTwins29 View Post
    I did agree with you, Lisa, that the prior office visit couldn't be used and that there had to be documentation of a current or admitting E/M service. However, while researching another question for our business office, I found this gem in the Medicare Claim Processing Manual, Chapter 12, section 30.6.9.1:

    "When a physician performs a visit that meets the definition of a Level 5 office visit several days prior to an admission and on the day of admission performs less than a comprehensive history and physical, he or she should report the office visit that reflects the services furnished and also report the lowest level initial hospital care code (i.e., code 99221) for the initial hospital admission. Contractors pay the office visit as billed and the Level 1 initial hospital care code."

    Now, it would be nice to have a definition of "several days" (IMO, your 6 day time frame would count as that for me), but in your scenario, if the visit on 11/9/11 was a 99215, then with this as my proof, I would assign 99221 for the 11/15/11 admission. But if the doc is looking to use these key elements to assign 99222 or 99223, then Houston, we have a problem.

    Do you think this would apply to the office visit documentation from one of the admitting physician's partners?
    Lisa Bledsoe, CPC, CPMA

  8. #8
    Location
    Ellenville, New York
    Posts
    1,177
    Default No
    Quote Originally Posted by Lisa Bledsoe View Post
    Do you think this would apply to the office visit documentation from one of the admitting physician's partners?
    I would not use anything from the partners. My reason for this is from the initial hospital care notes in the CPT book: ..."all evaluation and management service provided by THAT PHYSICIAN (emphasis mine) in conjunction with that admission are considered part of the intial hospital care..."

    I realize this may simply be interpretation on my part, but given this, even though the services are on different dates, I would not count services performed by the admitting MD's partners as part of the initial hospital visit E/M by the admitting MD.

    Lance Smith, MPA, COC, CPMA, CEMC, RHIT, CCS-P, CHC, CHPC

    Director, Health Information Management
    HealthAlliance of the Hudson Valley
    Kingston, NY


    2016 Secretary
    Ellenville, NY Local Chapter

  9. #9
    Location
    Greeley, Colorado
    Posts
    2,045
    Default
    Thank you; I am in agreement.
    Lisa Bledsoe, CPC, CPMA

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