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Thread: Addendum Complaince

  1. #1
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    Default Addendum Complaince

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    Good Morning Everyone,

    I work for a non-profit psychiatric clinic that sees client's on a sliding fee scale when they are not insured. I recently came across a very interesting issue and need some guidance.

    A client that we had previously seen for several years on sliding fee presented back to our clinic to resume her therapy, at which time we were informed that she has BCBS as of 10/1/11. No problem, right…

    Well BCBS has requested pre-existing information and requested all records beginning 10/8/08. Again, shouldn't be a problem….

    Well, while gathering the chart notes from 2008-2009, I originally thought that we were missing about 10 notes, which I absolutely couldn’t believe.

    After a ton of research, I discovered that one of our clinicians accidently listed dates as XX/XX/2008 instead of XX/XX/2009.

    The clinicians return to clinic notes for each one corresponds to the dates the client was seen in 2009; however the date of service is listed as 2008. I did verify that this client was not seen on the 2008 dates, only the 2009.

    So my question is, is there any law/guideline for adding and addendum to correct the date on these 10+ notes so that I can submit the information requested.

    I checked these forums, as well as CMS, and couldn't find an exact time limit, but I just wanted to double check. The only documentation we would be changing is date of service from XX/XX/2008 to XX/XX/2009.

  2. #2
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    Quote Originally Posted by jcochran View Post
    Good Morning Everyone,

    I work for a non-profit psychiatric clinic that sees client's on a sliding fee scale when they are not insured. I recently came across a very interesting issue and need some guidance.

    A client that we had previously seen for several years on sliding fee presented back to our clinic to resume her therapy, at which time we were informed that she has BCBS as of 10/1/11. No problem, right…

    Well BCBS has requested pre-existing information and requested all records beginning 10/8/08. Again, shouldn't be a problem….

    Well, while gathering the chart notes from 2008-2009, I originally thought that we were missing about 10 notes, which I absolutely couldn’t believe.

    After a ton of research, I discovered that one of our clinicians accidently listed dates as XX/XX/2008 instead of XX/XX/2009.

    The clinicians return to clinic notes for each one corresponds to the dates the client was seen in 2009; however the date of service is listed as 2008. I did verify that this client was not seen on the 2008 dates, only the 2009.

    So my question is, is there any law/guideline for adding and addendum to correct the date on these 10+ notes so that I can submit the information requested.

    I checked these forums, as well as CMS, and couldn't find an exact time limit, but I just wanted to double check. The only documentation we would be changing is date of service from XX/XX/2008 to XX/XX/2009.
    You should be able to *have the provider* make a correction - that's really not a big deal, just make sure that it's documented well on the note. I'm sure that happens all of the time, especially at the beginning of the year (I'll probably be stuck on 2011 until at least March)

    One question, though - is this an individual policy? If it's employer sponsored, or any other kind of group plan (fully or self-funded), the maximum pre-existing look-back period is 6 months prior to the effective date (4.1.10). They can only request 2 years for individual plans, so if I were you, I'd double check that before sending anything. You could end up with an unnecessary headache from denied claims, otherwise.

    Also, if the patient had prior credible coverage (a previous policy whose term date is within 63 days of 10.1.11), the amount of credible coverage from that policy, and from any other policies before that (again, without more than a 63 day lapse in coverage between plans), should be counted to deduct from the end of the pre-existing waiting period. The max waiting period, under HIPAA, is 12 months for group plans, and 18 months for individual plans; so if they had enough prior credible coverage to offset the pre-ex waiting period for their plan, you may not need to send records at all.

    You should contact the patient to find out if they've had any prior coverage, and get the effective and term dates for the policy (or policies) - if they're eligible for credit, have the patient obtain a Certificate of Creditable Coverage from each eligible policy, and send those to BCBS instead.

    It can be a hassle for them to do this, but I've found that if they understand how long they'll have denied claims for pre-existing conditions, that they'll have to pay out of pocket, without getting that stuff turned in, they're usually motivated to take care of it.

    Even if their prior coverage isn't enough to completely offset the whole waiting period, every little bit counts for something - maybe they'll only have a 6 month waiting period, versus the whole amount, when it's all said and done. It'll give you a good idea of how long you'll need to collect the whole allowable for conditions that you know will be denied as pre-ex.

    One last thing: always remember that with BCBS patients under a pre-ex waiting period, you have to include the condition onset dates in boxes 14 & 15 of the CMS-1500 (1st Tx Date & Similar Illness) - if you forget it, you should receive a denial asking for it relatively quickly; but that's one you can fix over the phone. Good luck!
    Last edited by btadlock1; 12-29-2011 at 12:52 PM. Reason: important thing added

  3. #3
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    Quote Originally Posted by btadlock1 View Post
    You should be able to *have the provider* make a correction - that's really not a big deal, just make sure that it's documented well on the note. I'm sure that happens all of the time, especially at the beginning of the year (I'll probably be stuck on 2011 until at least March)

    One question, though - is this an individual policy? If it's employer sponsored, or any other kind of group plan (fully or self-funded), the maximum pre-existing look-back period is 6 months prior to the effective date (4.1.10). They can only request 2 years for individual plans, so if I were you, I'd double check that before sending anything. You could end up with an unnecessary headache from denied claims, otherwise.

    Also, if the patient had prior credible coverage (a previous policy whose term date is within 63 days of 10.1.11), the amount of credible coverage from that policy, and from any other policies before that (again, without more than a 63 day lapse in coverage between plans), should be counted to deduct from the end of the pre-existing waiting period. The max waiting period, under HIPAA, is 12 months for group plans, and 18 months for individual plans; so if they had enough prior credible coverage to offset the pre-ex waiting period for their plan, you may not need to send records at all.

    You should contact the patient to find out if they've had any prior coverage, and get the effective and term dates for the policy (or policies) - if they're eligible for credit, have the patient obtain a Certificate of Creditable Coverage from each eligible policy, and send those to BCBS instead.

    It can be a hassle for them to do this, but I've found that if they understand how long they'll have denied claims for pre-existing conditions, that they'll have to pay out of pocket, without getting that stuff turned in, they're usually motivated to take care of it.

    Even if their prior coverage isn't enough to completely offset the whole waiting period, every little bit counts for something - maybe they'll only have a 6 month waiting period, versus the whole amount, when it's all said and done. It'll give you a good idea of how long you'll need to collect the whole allowable for conditions that you know will be denied as pre-ex.

    One last thing: always remember that with BCBS patients under a pre-ex waiting period, you have to include the condition onset dates in boxes 14 & 15 of the CMS-1500 (1st Tx Date & Similar Illness) - if you forget it, you should receive a denial asking for it relatively quickly; but that's one you can fix over the phone. Good luck!
    Thanks so much for your reply! I will have the clinician write at the bottom that we are correcting the dates of service.

    As far as the client's insurance policy, it is an individual plan, and they are requesting the last 2 years from the day that the client was eligible for her BCBS plan. The client did not have any other credible coverage before 10/8/2011 unforutnately. I do appreciate the suggestion in checking with this Thanks so much for your answer! I just wanted to make sure that I was not doing anything wrong by having the clinician put the addendum in since these notes are 18 months old.

    Thanks
    Jessica

  4. #4
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    Quote Originally Posted by jcochran View Post
    Thanks so much for your reply! I will have the clinician write at the bottom that we are correcting the dates of service.

    As far as the client's insurance policy, it is an individual plan, and they are requesting the last 2 years from the day that the client was eligible for her BCBS plan. The client did not have any other credible coverage before 10/8/2011 unforutnately. I do appreciate the suggestion in checking with this Thanks so much for your answer! I just wanted to make sure that I was not doing anything wrong by having the clinician put the addendum in since these notes are 18 months old.

    Thanks
    Jessica
    Nah...you're good - you have billing records that reflect it, I assume? That's a simple mistake.

    A problematic addendum example, would be something like, if you noticed that you billed for an injection on an old date of service, and there was no record of it in the chart; or if the level of service and/or diagnosis reported weren't supported by the documentation... so the doctor decided just to add it.
    If he genuinely remembered what he's writing (who knows - maybe he's got an elephant's memory), then even that's not against the law, per se, when it's documented correctly (he should sign the addendum, put the date that the changes were made, and include something about how the error was discovered, with any type of addendum - red ink would be preferrable, as well).

    There's not really a specific time-limit for making corrections in any laws, but the legitimacy of the correction, may be questioned if it's really old, depending on the nature of the info corrected.

    From the sound of it, your patient is in for the long-haul on their pre-ex, and probably won't have any visits to your doc covered for the next year or so (assuming s/he's having a condition like ADHD or depression managed, at least). She can always cross her fingers and hope PPACA isn't repealed before 2014, I suppose. At least then, this will be the last time she has to deal with this crap.

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