Amending the Medical Record
Diana Williams, BS, CPC, CCS-P, CCS, CPMA
CMS is aware that amendments, corrections, and delayed entries occur in the medical record. Occasionally upon review, a provider may discover that certain entries, related to actions that were actually performed at the time of service, were not properly documented or entered after rendering the service. Whether a documentation submission originates from a paper record or an electronic health record, amendments, corrections, or addenda must:
- Clearly and permanently identify any amendment, correction, or delayed entry, as such.
- Clearly indicate the date and author of any amendment, correction, or delayed entry.
- Not delete, but instead clearly identify, all original content.
“Timeliness” of medical documentation is a related concern.
- A provider may not submit a claim to Medicare until the documentation is completed. Until the practitioner completes the documentation for a service, including signature, the practitioner cannot submit the service to Medicare. Medicare states if the service was not documented, it was not done.
- Practitioners are expected to complete the documentation of services “during or as soon as practicable after it is provided in order to maintain an accurate medical record.”
- CMS does not provide a specific time in which documentation must be completed, but a reasonable expectation is no more than a couple of days after the service, itself.