Skip Navigation Links
Home
Contact Us
About Us
Core ServicesExpand Core Services
Patient ServicesExpand Patient Services
CMBS Job OpportunitiesExpand CMBS Job Opportunities
 
SiteMap SiteMap

Returned Records

By Sharon L. Nicka, RN, CPC

In my last article, I shared with you a list of the Top Five Documentation Deficiencies. Since that time, I have encountered a lot of discussion regarding deficient vs. returned records. What is or should be the distinguishing factor between these two?  I can tell you that this is a hot OIG question as well!

 Deficiency charts are records that have identified deficiencies and have been coded ‘as is'. Down-coding and missed procedure charges occur with inadequate or missing documentation of a chart component(s). A returned record is a chart that has not (or can not) be coded and is returned for further documentation or clarification. A general policy is to return charts that have missing whole sections of the HPI and PE, Critical Care, and/or for clarification of procedures.

So, do you know what your group or hospital policies are regarding deficient vs. returned charts? I encourage you to take a good look at your practices through both reimbursement and compliance perspectives. If the chart is code-able and being sent back primarily for reimbursement purposes, red compliance flags may be waving your way.

Having said that, let's focus on returned charts. All physician groups and hospitals should have policies to address how a chart can be amended. Specific procedures and time frames should be developed and followed for processing an amendment. A separate entry (progress note, form, typed letter) can be used for amendment documentation. 

Late Entry - When a pertinent entry was missed or not written in a timely manner, a late entry can be used to record the information in the original medical record.

  • Identify the new entry as “late entry.”
  • Enter the current date and time. Do not try to give the appearance that the entry was made on a previous date or time.
  • Identify or refer to the date and incident for which the late entry is written.
  • If the late entry is used to document an omission, validate the source of additional information as much as possible (e.g., where you obtained the information to write the late entry).
  • When using late entries, document as soon as possible. There is no time limit to writing a late entry; however, the more time that passes, the less reliable the entry becomes.

Addendums - An addendum is another type of late entry that is used to provide additional information in conjunction with a previous entry. With this type of correction, a previous note has been made and the addendum provides additional information to address a specific situation or incident. When making an addendum:

  • Document the current date and time.
  • Write “addendum” and state the reason for the addendum referring back to the original entry.
  • Identify any sources of information used to support the addendum.
  • When writing an addendum, complete it as soon after the original note as possible.
  • In an electronic system it is recommended that organizations have a link to the original entry or a symbol by the original entry to indicate the amendment. ASTM and HL7 have standards related to amendments.

Of course the best way to address all documentation is to focus on the details during the original patient encounter.  Reducing the number of deficient and returned records will go a long way to minimizing compliance risk and appropriately improving reimbursement!

 Login Refund Policy  | Privacy Policy  | Industry Links  

© 2004 Comprehensive Medical Billing Solutions, Inc., All Rights Reserved