CMS Provides Guidance For Amending Patient Medical Records

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CMS recently released a transmittal providing instructions to contractors on acceptable methods for providers to amend, correct and incorporate delayed entries into a patient medical record. The transmittal amends the Medicare Program Integrity Manual (CMS Pub. 100-08) to delineate recordkeeping principles which providers must follow when making alterations to a patient record subsequent to the time of service, including: (1) clearly and permanently identifying any amendment, correction or delayed entry as such; (2) clearly indicating the date and author of the amendment, correction or delayed entry; and (3) not deleting but instead clearly identifying all original content (Recordkeeping Principles). Recordkeeping Principles are necessary whether the documentation submission originates from a paper record or an electronic health record. If altering a paper record, the author should use a single line strike-through to ensure the original content is still readable and sign and date any revision or additional entry. The transmittal directs contractors to disregard any entries that do not comply with the Recordkeeping Principles, even if such exclusion would lead to a claim denial.

Transmittal 442, Change Request 8105, effective date of January 8, 2013, can be found online.

For more information, please contact Robert M. Wolin, rwolin@bakerlaw.com or 713.646.1327, or Summer D. Swallow, sswallow@bakerlaw.com or 713.646.1306.