Part B Insider (Multispecialty) Coding Alert

What If the Patient Disagrees With the Information in Her Records?

Published on Mon Mar 07, 2016

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It happens from time to time—you share a copy of the patient’s medical records with her, and she asks you to change things in the notes that she sees as a discrepancy. Although you might want to brush off the issue, the reality is that you must address it.

In black and white: “If you think the information in your medical or billing record is incorrect, you can request a change, or amendment, to your record,” the government says in the patient-education fact sheet Your Medical Records on HHS.gov. “The health care provider or health plan must respond to your request. If it created the information, it must amend inaccurate or incomplete information.”

This doesn’t mean you have to change everything that the patient requests, but you must look into it. “If the clinician disagrees with the amendment, the patient must be notified in writing of the following,” advised Candice Fenildo, CPC, CPMA, CPB, CENTC, during her presentation “HIPAA and Meaningful Use” at The Coding Institute’s December CodingCon:

Basis for the denial
The right to file a statement of disagreement to be kept in their file and included with future PHI disclosures
Their right to complain to the covered entity or Secretary of HHS
Contact information for the covered entity’s Privacy Officer.