Addendums, Amendments, and Late Entries
Our documentation is being held to a higher standard and scrutinized more frequently by insurance carriers. This can cause some concern among providers to ensure all pertinent information gets conveyed through the electronic health records. I was not able to find a time limit concerning when information can effectively be added to a patient's medical record except that it must be "timely recorded".
Addendums add information to the original record or entry. Amendments clarify health information after the original health record is completed, and late entries are entered after the point of service is completed. Understand though if information is added to a health record, it may be further scrutinized and more questions may be asked than anticipated. As providers of therapy services, we should document during a therapy session. But how can we expertly justify spending 3-5 minutes to document a note when we are not actively engaged in a therapeutic procedure with the patient?
If I have a patient on the mat table doing SAQs and I sit next to him while using my laptop to write a note, thereby not engaging the patient for 3 minutes, does that qualify as therapeutic minutes being spent with the patient? Three minutes can be the difference between a RU and an RV reimbursement rate. Multiply that by eight patients a day and clearly there is some serious money at stake. On the other hand if I wait until the end of the day to do my documentation, do all the notes have to be late entries?
To further darken the waters on documentation, do I have to be in line of sight of the patient or even in the same room for my minutes to count with the patient? What if the patient is getting dressed behind a curtain and I document my therapy session at a table across the room, do those minutes count? And is a curtain considered a separate area (room) from where a therapist is documenting? Or would it be easier for me to put an amendment or addendum attached to the medical record later, clarifying my intent during the therapy session.
In the world of insurance providers and paying for therapy services, a couple of minutes can be the difference between several hundred dollars in reimbursement claims. We should not expect an insurance provider to pay us simply because we are standing in the same room as a patient.