All services should be documented in the patient's medical record at the time they are rendered. Sometimes services that may have been provided were not properly documented. In this instance, the documentation will need to be amended, corrected, or entered after the service is rendered.
When reviewing medical documentation and making review determinations we will consider all submitted entries that comply with the widely accepted recordkeeping principles
Regardless of whether documentation is submitted from a paper record or an electronic health record, documents submitted 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.
When correcting a paper medical record, these principles are generally accomplished by:
Using a single line strike through so the original content is still readable, and
The author of the alteration signing and dating the revision
Amendments or delayed entries to paper records may be initialed and dated if the medical record contains evidence associating the provider’s initials with their name.
Medical record keeping within an EHR deserves special considerations; however, the principles specified above remain fundamental and necessary for document submission. 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
We will not consider any entries that do not comply with the recordkeeping principles.
CMS Internet-Only Manual, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.5
If you have additional questions regarding your medical review, please contact the nurse reviewer assigned to your case. If you have additional education needs associated with the content of this article, please contact our Provider Outreach and Education team.
This material is proprietary information of Novitas Solutions, Inc. This material may not be duplicated, in whole or in part, for profit-making purposes. Novitas and its staff make no representation, warranty, or guarantee this compilation of Medicare information is not error-free, nor that use of this information will prevent differences of opinion or disputes with Medicare.
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