Documenting Correctly

Documentation errors don't just create compliance headaches—they can lead to denied claims, recoupments, and unwanted audit scrutiny. In this episode of Reimbursement Readiness, Kathleen Schaum welcomes reimbursement consultant Donna Cartwright to discuss Medicare's rules for medical record documentation, late entries, addendums, and corrections. Together, they review what auditors look for, when documentation changes are appropriate, how to properly amend records, and why waiting too long to make corrections can create significant risk. Whether you're a clinician, coder, biller, revenue cycle leader, or compliance professional, this episode offers practical guidance to help ensure your documentation accurately reflects the care provided and stands up to audit review. Topics include: Medicare guidance on late entries, addendums, and corrections Documentation expectations during audits and ADRsCommon documentation mistakes that raise red flags Best practices for paper and electronic medical recordsAudit risks associated with delayed documentation changes When—and when not—to amend the medical record This episode also addresses one of the most frequently asked audit questions: Can you go back and change a medical record before submitting it for review? Episode Evaluation link: ⁠https://forms.office.com/Pages/Respon...