¶¶Òô´ó¹Ï members may submit coding inquiries electronically to codingquestions@asge.org. When submitting a question, please allow at least three business days for a response. When submitting inquiries, please include the ¶¶Òô´ó¹Ï member’s name and ID number. Only questions will be accepted and not reports. Below is our featured Coding Question of the Month that could be beneficial to your practice.
Question:
When a note is signed, is it a legal document and should it not be unlocked to make any changes? Moreover, should any changes be made in an addendum? Is there documentation about this somewhere, or is there an authoritative source that could be referenced for my place of employment?
Answer:
CMS gives guidance regarding signature requirements in the MPIM (Medicare Program Integrity Manual) which states: Signatures are required upon medical review for two distinct purposes: 1. To satisfy specific signature requirements in statute, regulation, national coverage determination (NCD) or local coverage determination (LCD); and 2. To resolve authenticity concerns related to legitimacy or falsity of the documentation.
If a record needs to be corrected or amended, it must be done in the form of a legal addendum. Below is a link to a CMS transmittal regarding addendums.
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For more information, you can refer to the Medicare Program Integrity Manual, consult a healthcare attorney, or search online for resources to help you gather relevant information to share with your providers.