If physician documentation is missing or does not support the level or evaluation and management (E&M) service billed, surgery performed, or durable medical equipment (DME) issued, an addendum should be requested from the physician. A valid addendum must be received before the claim is submitted.
Reporting our lead story during this of Talk Ten Tuesdays will be Terry Fletcher, nationally recognized professional physician coder and auditor. Fletcher reports on the need to know how to correctly make these changes, but also, to know the difference between a "late entry" and an addendum to a medical record – and how Medicare's Program Integrity Manual relates it to reimbursement, compliance, and best practices.
The podcast also feature these other segments: