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  • Amending Chart Notes Following Payer Audit


    We received a Targeted Probe and Educate (TPE) audit and while pulling charts identified documentation errors. Are we allowed to go back to other records from that same time and amend them in case of a second-round request for additional charts?

    Answer:
    Once signed by the physician, do not reopen a chart and edit old notes. Create an addendum, late entry or correction with the current date and have the physician sign the amendment. From Fundamentals of Ophthalmic Coding

    • Ensure that addendums to chart notes are additions or clarifications, never replacements for original documentation.
    • Properly documented addendums or alterations (Ideally, the medical record should be completed within a short time after the exam; any additions to the record should be clearly indicated as such and should include the date, time, and reason for the addendum.)

    Access guidance from Noridian, a Medicare administrative contractor (MAC) on amended medical records and the definition of falsified documentation.

    Just as their name implies, Targeted Probe and Educate audits are used for education. Adding amendments to old records is allowed when appropriate and done properly and shows improved compliance. The most important thing is for all dates of service going forward to be correct. TPE audits can be pre- or post-payment reviews and will continue post failure up to three rounds, followed by more extensive audits from the Recovery Auditor Contractors (RA or RAC) if continued deficiencies are found. If you pass a round, they will not audit for one year. Academy members can access additional information on audits at aao.org/audits.