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Documentation Correction Guidelines

CMS allows for the use of addenda to correct documentation in a medical record note used for risk adjustment.   Only the attending provider can correct the medical record. The corrections should be within 30 days of the initial documentation, and substantial reasoning must be provided for the change. The amendment should be based on a face-to-face visit on the date of service and signed by the physician.  Addendums should be the exception and not the rule.  

Guidelines for appropriate use…

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