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Addendum

Leorah Posted Mon 24th of June, 2019 04:03:07 AM
Our doctor added an addendum note to another doctors notes that is not within our practice for an inpatient E&M visit. Can we code for that addendum? The addendum was written as follows " History and Neuro exam discussed with resident in real time imaging reviewed. Agree with Dr. ______ assessment and plan." Then our dr. listed recommendations and follow up.
SuperCoder Answered Tue 25th of June, 2019 04:55:16 AM

Hi,

Thanks for your question.

An addendum is used to provide information that was not available at the time of the original entry. The addendum should also be timely and bear the current date and reason for the addition or clarification of information being added to the medical record and be signed by the person making the addendum.

It appears from addendum verbiage that resident performed the history and neuro examination and the teaching physician added an addendum of verbiage therefore the criteria for “incident to” should be met to bill this service.

Incident to criteria requirements are as follows:

  • The physician must personally perform the initial service and remain actively involved in the patient’s care.
  • The physician must be in the office suite when the services are performed.
  • Generally, services must be performed in the office (there are some exceptions).
  • Must represent an expense to the physician.   
  • Medically necessary.

Please go through with the medical record documentation to look for "incident to" criteria to be fulfilled.

Hope this helps.

Thanks.

Leorah Posted Wed 26th of June, 2019 05:42:43 AM
I am confused by your classification, since I am under the impression that 'incident to' needs to be rendered in the doctors office or place of service 11 while this service was rendered in the inpatient hospital setting which is place of service 21. Please confirm or deny that 'incident to' may be rendered in the inpatient setting. Thank you
SuperCoder Answered Thu 27th of June, 2019 10:56:51 AM

Hi,

You are correct that the "incident to" criteria cannot be applicable for inpatient setting.

An addendum is used to provide information that was not available at the time of the original entry. The addendum should also be timely and bear the current date and reason for the addition or clarification of information being added to the medical record and be signed by the person making the addendum.

Based on the above criteria the addendum can be coded.

Also, for better attesation the physician can use statements, for example:

  • “I performed a history and physical examination of the patient and discussed his management with the resident. I reviewed the resident’s note and agree with the documented findings and plan of care.”
  • “I saw and evaluated the patient. I agree with the findings and the plan of care as documented in the resident’s note.”
  • “I saw and examined the patient. I agree with the resident’s note, except the heart murmur is louder, so I will obtain an echo to evaluate.”

Hope this helps.

Thanks.

Leorah Posted Sun 07th of July, 2019 05:34:48 AM
What code would I use for the addendum listed above?
SuperCoder Answered Mon 08th of July, 2019 10:39:27 AM

Hi,

The patient was seen in inpatient hosptial care then code ranges which are given below will be used.

Please select the appropriate code based on the medical record documentation. 

99221-99223 Initial Hospital Inpatient Care Services

99231-99233 Subsequent Hospital Care

99234-99236 Observation or Inpatient Care Services (Including Admission and Discharge Services)

99238-99239 Hospital Discharge Services

 

Hope this helps.

Thanks.

 

Leorah Posted Wed 10th of July, 2019 12:12:44 PM
That's interesting because when we looked at https://www.lacare.org/sites/default/files/universal/cms_1500_form_instructions.pdf it says "When a service is incident to the service of a physician or nonphysician practitioner, the name of the physician or non-physician practitioner who performs the initial service and orders the nonphysician service must appear in item 17; • When a physician extender or other limited licensed practitioner refers a patient for consultative service, submit the name of the physician who is supervising the limited licensed practitioner." Is this wrong?
SuperCoder Answered Thu 11th of July, 2019 09:15:04 AM

Hi,

Thanks for your question.

It is correct that when a service is incident to the service of a physician or nonphysician practitioner, the name of the physician or non-physician practitioner who performs the initial service and orders the nonphysician service must appear in item 17.

As per your initial question the addendum can be billed during the inpatient and consultation services. Also, please check the place of service where you are billing the incident to. Because as mentioned above incident to guidelines cannot be applicable at inpatient setting.

Hope this helps.

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