Corporate

NOTE: This article has been replaced. The most recent article on this topic—published on January 19, 2016— is available here:

December 26, 2012 - Revised: 01.19.16

Entries in Medical Records: Amendments, Corrections, and Delayed Entries

All services provided to beneficiaries are expected to be documented in the medical record at the time they are rendered. Occasionally, certain entries related to services provided are not properly documented. In this event, the documentation will need to be amended, corrected, or entered after rendering the service.

When making review determinations the MACs, Comprehensive Error Rate Testing (CERT) contractor, Recovery Auditors (RAs), and ZPICs shall consider all submitted entries that comply with the widely accepted Recordkeeping Principles described below. The MACs, CERT, RAs, and ZPICs shall NOT consider any entries that do not comply with these principles, even if such exclusion would lead to a claim denial. For example, they shall not consider undated or unsigned entries handwritten in the margin of a document. Instead, they shall exclude these entries from consideration.

Recordkeeping Principles: (CMS Publication 100-08 Medicare Program Integrity, Chapter 3, section 3.3.2.5External PDF)

Regardless of whether a documentation submission originates from a paper record or an electronic health record, documents submitted to MACs, CERT, Recovery Auditors, and ZPICs containing amendments, corrections or addenda must:

  • Clearly and permanently identify any amendment, correction or delayed entry as such, and
  • Clearly indicate the date and author of any amendment, correction or delayed entry, and
  • Clearly identify all original content, without deletion

Paper Medical Record

  • Use a single linestrike-through (like this) so the original content is still readable, and
  • The author of the alteration must sign and date the revision.

Electronic Health Records (EHR)

Medical record keeping within an EHR deserves special considerations; however, the principles specifiedabove remain fundamental and necessary for document submission to MACs, CERT, Recovery Auditors, and ZPICs.

Records sourced from electronic systems containing amendments, corrections or delayed entries must:

  • Distinctly identify any amendment, correction or delayed entry, and
  • Provide a reliable means to clearly identify the original content, the modified content, and the date and authorship of each modification of the record.

Reference:


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