If a billing modifier is added to a CPT® code at the billing/claims processing stage, what is the compliance that must be met? Is it mandatory that the chart be updated with the added modifier? I believe so, however, I have not found this clarification in any compliance documentation. If anyone can direct me to this, very much appreciated.
(The only compliance I've read relates to updating DXs and changes in root CPT®, not modifier addition.)
Thank you!