Ophthalmology and Optometry Coding Alert

Question: One of our physicians made mistakes on several charts and printed out new documentation to replace the old notes. Our office manager isn’t comfortable with this. Can you advise?

Texas Subscriber

Answer: Although it is legal to amend your records, you cannot simply throw out the original documentation and replace it with something new, because payers could consider that “record tampering.”

As long as the doctor actually remembers the information, or reads notes or other written information that triggers their memory of the additional information, they can add information at any time. Follow these steps to make sure your corrections will pass a review:

1. Cross out old information rather than deleting it. If you are correcting an incorrect statement in the record, you should draw a line through the statement and put the word “error” next to it. Then sign or initial it (depending on your policy) and put the date. The original information must still be readable and included in the record. Use just a single line to cross it out.

2. Title the late entry. Never make a late entry appear like it was there all along. Be sure to clearly mark the correction or supplementation as a late entry with a title such as  “Addendum to the medical record made on Dec. 15, 2021 by Steve Smith, M.D:”

3. Include signature and date. Any late entry should include its date, and corrections or additions to documentation should ideally be made by the documentation’s original author. That person should sign the correction as well as dating it.

4. Add the reason. It’s a good idea to note the purpose of the entry — for example, clarification. It’s also helpful to indicate the source of the additional information, such as based on notes jotted during the visit.

5. Remember hard copies. If you make a correction in the electronic health record (EHR) and there was also a hard copy printed from the electronic record, the hard copy must also be corrected.