Documentation Reminders: Addendums and Documentation of Time

The following information is a reminder of requirements for documentation of addendums to the medical record and documentation of time.

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

Adding the addendum of additional information does not replace the original information. The original information is left in the documentation with a line placed through that entry to indicate the information the addendum is replacing.

Corrections to the medical record prior to the claim’s submission will be considered in determining the validity of the services billed. If changes appear in the record following a request for medical records, a medical review or audit, only the original record will be reviewed when making determinations.

Addendums or corrections should never be common occurrences. It is important to review your documentation for accuracy to ensure that correct and complete information is entered.

Documentation of Time

Documentation is expected to be specific to the patient and each individual encounter to help ensure that appropriate reimbursement can be determined, supporting the services billed. Documentation of time on the date of the encounter/visit should include the total time of the service performed and should not merely reflect the scheduled time with the patient. A best practice for providers would be to document the time in and time out of the visit with the patient.

Services billed with Current Procedural Terminology (CPT®) codes based on the time spent performing the service are considered time-based services. Examples of time-based services include, but are not limited to, certain evaluation and management services, psychotherapy services and other types of therapy services.

When billing for services such as therapy, time-based CPT® codes are identified as timed codes with one unit representing a 15-minute increment. In each instance, a unit of time is attained when the mid-point is reached as instructed in the CPT® manual. An example of documenting direct patient contact includes “nine minutes was spent with the patient performing the therapeutic activity.”

Time-based services may require documentation of face-to-face time or direct (one-on-one) patient contact. For evaluation and management services, examples of documenting face-to-face time include: “50 minutes was spent face-to-face with the patient, of which 35 minutes was spent in counseling,” or “53 minutes was spent face-to-face with the patient for psychotherapy.”