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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:

  1. Clearly and permanently identify any amendment, correction, or delayed entry, as such.
  2. Clearly indicate the date and author of any amendment, correction, or delayed entry.
  3. 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.
John Verhovshek
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About Has 577 Posts

John Verhovshek, MA, CPC, is a contributing editor at AAPC. He has been covering medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University.

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