Making Amendments, Corrections, and Delayed Entries in Medical Documentation
As with most things, when documenting in the medical record, it’s best to “get it right” the first time. And because human memory isn’t as reliable as we’d like to believe, it’s also best to document the patient encounter as it is rendered, or as shortly thereafter as possible. When amendments, corrections, or delayed entries in medical documentation must be made, the Medicare Program Integrity Manual (chapter 3, section 3.2.5) stipulates certain guidelines:
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.
The Manual details the specific means by which these instructions may be achieved 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 must sign and date the revision.
Amendments or delayed entries to paper records must be clearly signed and dated upon entry into the record. 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.
The Manual goes on to note:
Medical record keeping within an EHR deserves special considerations; however, the principles specified above 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.
Payers may not honor documentation that does not meet these guidelines. For example, a payer may rightly disregard undated or unsigned entries handwritten in the margins of a document.
Note that the Manual does not specify a time period during which amendments, corrections, or delayed entries may occur. Common sense suggests, however, that entries made weeks or months after the fact are likely to be treated as justifiably suspect. Per the Program Integrity Manual, “If the MACs, CERT or Recovery Auditors identify medical documentation with potentially fraudulent entries, the reviewers shall refer the cases to the ZPIC and may consider referring to the RO and State Agency.”