Part B Insider (Multispecialty) Coding Alert

Published on Fri Feb 22, 2013 PDF

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Ever wondered why following the regulations is of paramount importance when you’re amending a medical record? An Illinois physician found out the hard way, pleading guilty to obstruction of a criminal health care fraud investigator on Feb. 14 and now faces up to 10 years in prison and a $250,000 fine.

The physician received a subpoena for his medical records, but before turning them over to the government official, the doctor altered a progress note to show an in-office examination that hadn’t actually taken place. The physician had billed the visit to his insurer, so he created the fake note later to support his claim.

Because of physicians like this, insurers are on the lookout for backdated or altered medical records. Therefore, if you need to amend your medical record, stick to the rules, which require you to identify it as an amendment, and the practitioner should sign and date it. Never delete the original entry--instead, ensure that all original content is identifiable. You can do this on a paper record by using a single strike line through the original content. For an EHR, you must "provide a reliable means to clearly identify the original content, the modified content, and the date of authorship of each modification of the record," CMS says.

To read about the Illinois physician, visit www.justice.gov/usao/ils/News/2013/Feb/02142013_Yassin Press Release.html.