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E & M question on physical exam

Susan Posted Fri 07th of September, 2018 13:08:35 PM
If a provider failed to mark under rule of symptoms and failed to note the negatives under the physical exam the provider wants to do an addendum to the completed visit , would it be legal to state for the physical exam all systems normal except ones noted under the HPI......
SuperCoder Answered Mon 10th of September, 2018 08:29:23 AM

Hi,
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 seems like your question is directed towards marking Review of Systems (ROS) as per the verbiage all systems normal except ones noted under the HPI. You can add the addendum but the above stated guidelines should be met. Ensure that the physician performed the key component (HPI, ROS or Physical exam) while doing the evaluation and management before submitting for the claim otherwise it might become a false claim.

Thanks.

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