If ER physician did not document an exam or HPI (I know that is a problem), would it be appropriate to send the physician a query to add a late entry/addendum? This would occur the next day not weeks later.
I’ve look at several links and have tried to find solid information on this. All the information I find is about timeliness. The ER charts are locked after 48 hours here at our facility but it does not address the issue of sending queries.
One person in management says, "due to missing physician documentation we cannot query for additional information in order to assign a higher level. CMS considers this leading." How is it leading if I am asking the doctor to complete the documentation? I am not leading, merely stating—Dr. ???? in your ER note you are missing documentation on ????. ( the physician has not documented anything for the portion I am querying.) I would not send a query even if the physician put one element.
How would the 3.3.2.5-Amendments, Corrections and Delayed Entries in Medical Documentation be implemented then?
https://www.cms.gov/Regulations-and-…s/pim83c03.pdf
I’ve asked other coders and there reaction is, "it is not leading to ask them to complete the documentation."
In addition, in one of AAPC’s training programs it is stated, "An addendum to include information about what was done to the patient, or any test results, should be added within a reasonable time frame, usually capped at a maximum of 60 days after the encounter."
Please tell me what you think. The new management does not provide information to clarify there statement.
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