Question Making amendments to a medical record AFTER documents are requested for review

medicalauditor

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Hi guys,
I know that it is illegal to make corrections to a medical record after a denial, in order to get the claim paid, or after documents are requested by a payor. In fact it is not appropriate to make any changes after a claim is submitted. I found several resources that confirm this, including Noridian and some commercial payors. However, I can't seem to find any CMS or OIG document that explicitly states this. Can someone please guide me to a CMS or OIG document that talks about this? Thank you so much.
 

thomas7331

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Hi guys,
I know that it is illegal to make corrections to a medical record after a denial, in order to get the claim paid, or after documents are requested by a payor. In fact it is not appropriate to make any changes after a claim is submitted. I found several resources that confirm this, including Noridian and some commercial payors. However, I can't seem to find any CMS or OIG document that explicitly states this. Can someone please guide me to a CMS or OIG document that talks about this? Thank you so much.
Are you sure about this? I'm not aware of any law or regulation that makes illegal to make changes to a medical record (I'm assuming you mean make an amendment here) - it is just that many payers and contractors have policies that they will not consider those changes if they were made at a later date than when the claim was submitted or when the payment determination was made. In other words, while it could be considered fraudulent to change the record to add documentation and to use that new information in order to rebill the claim for purposes of reversing a denial or obtaining a higher payment, it is not illegal to amend the record if errors are found.

I haven't see this addressed explicitly by CMS as I think this is something that is delegated to the contractors and the audit firms to set their own policies for.

In cases where I've identified an actual and material error in the record after receiving a request for a review, my approach with the payers has been to be completely honest with them - i.e. explain that we recognized the error at the time of the request, made the necessary amendment at that time, and alert them to fact that we understand that this part of the documentation was not present at the time original claim. That way you can ensure the integrity of the record without being accused of making the change solely for the purposes of a positive audit outcome. Then it would be up to the auditor to either honor that change or not.
 
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csperoni

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I'm with Thomas on this.
For example, at the time of a claim denial, you realize everywhere except 1 note says a mass is on the left side. On one note, for one day, someone accidentally typed right side. I would have no issue with an amendment to correct that clearly incorrect note to left side, which would also change your ICD10.
Or let's say the physician dictates a bilateral oophorectomy (ovary removal). He/she also removed the fallopian tubes, but forgot to dictate it (I know, clearly not good, but it does happen because physicians are human). The notes show a plan for tubes and ovaries. The consent is for tubes and ovaries. The specimens removed were tubes and ovaries. The pathology is of tubes and ovaries. It would not be illegal to correct the record.
In those situations, as Thomas said, you should not present your amended/corrected documentation as though it was the original. Present it accurately as a recently discovered correction and let the payor or auditor decide whether or not to pay for those services not in the original documentation.
These situations could even be in the benefit of the payor. In my tubes and ovaries example, flip it. Physician dictates tubes and ovaries but only really removed ovaries. You would send a corrected claim whenever you realized the error.
Clearly, it would be illegal to falsify a medical record (either before or after a denial) as a means to receive payment.
 

ccallycat

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Agree with above comments, I have not had an issue with having my provider add an amendment at the end of the report, stating what was also done but not previously reported in report, and its always dated for when the amendment was added. In addition I'll attach other reports such as pathology or maybe even previous notes/post op notes. But if you are talking about adding to the original report as if it was documented at the time of service, then no, would not do that. That's treading on dangerous grounds, and is making it look like your adding it just to get paid.

As far as a link to support that, I probably only saw what you did under google search:

Is It Illegal to Alter Medical Records? Altering a medical record is a crime and can also be used against doctors in medical malpractice cases. However, it is not illegal for medical professionals to make honest updates to records, as long as they properly mark what they are doing and do not obscure information.
 

medicalauditor

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Are you sure about this? I'm not aware of any law or regulation that makes illegal to make changes to a medical record (I'm assuming you mean make an amendment here) - it is just that many payers and contractors have policies that they will not consider those changes if they were made at a later date than when the claim was submitted or when the payment determination was made. In other words, while it could be considered fraudulent to change the record to add documentation and to use that new information in order to rebill the claim for purposes of reversing a denial or obtaining a higher payment, it is not illegal to amend the record if errors are found.

I haven't see this addressed explicitly by CMS as I think this is something that is delegated to the contractors and the audit firms to set their own policies for.

In cases where I've identified an actual and material error in the record after receiving a request for a review, my approach with the payers has been to be completely honest with them - i.e. explain that we recognized the error at the time of the request, made the necessary amendment at that time, and alert them to fact that we understand that this part of the documentation was not present at the time original claim. That way you can ensure the integrity of the record without being accused of making the change solely for the purposes of a positive audit outcome. Then it would be up to the auditor to either honor that change or not.
Maybe it'll help if I give more information - In this case, addendums were created after medical records were requested for review and the reason the provider office stated for this, in their cover letter, is "due to audit and review of records for correct coding." Changes were made to diagnoses and chief complaint, but other than saying an addendum was created due to audit & review, there is no other explanation for why diagnoses were changed/added and how can a chief complaint change after several months of the visit, only because records are requested? From what I can see, the patient had come in primarily for her obesity and the addendum makes it look like obesity was incidental and the primary concern was something else. Not just that, its hard to tell exactly what changes were made, from looking at the addendum. I do know that CMS clearly states that the original content cannot be deleted or overwritten, when making amendments. I have asked for clarification and to see the original chart note so I will know exactly what was changed, after I review the document. I do know, like many of you are stating, that modifying or adding to a medical record with the objective of getting paid, is fraudulent, but I can't find a reliable source that explicitly states this. Can someone help? Thank you.
 

medicalauditor

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I'm with Thomas on this.
For example, at the time of a claim denial, you realize everywhere except 1 note says a mass is on the left side. On one note, for one day, someone accidentally typed right side. I would have no issue with an amendment to correct that clearly incorrect note to left side, which would also change your ICD10.
Or let's say the physician dictates a bilateral oophorectomy (ovary removal). He/she also removed the fallopian tubes, but forgot to dictate it (I know, clearly not good, but it does happen because physicians are human). The notes show a plan for tubes and ovaries. The consent is for tubes and ovaries. The specimens removed were tubes and ovaries. The pathology is of tubes and ovaries. It would not be illegal to correct the record.
In those situations, as Thomas said, you should not present your amended/corrected documentation as though it was the original. Present it accurately as a recently discovered correction and let the payor or auditor decide whether or not to pay for those services not in the original documentation.
These situations could even be in the benefit of the payor. In my tubes and ovaries example, flip it. Physician dictates tubes and ovaries but only really removed ovaries. You would send a corrected claim whenever you realized the error.
Clearly, it would be illegal to falsify a medical record (either before or after a denial) as a means to receive payment.
Maybe it'll help if I give more information - In this case, addendums were created after medical records were requested for review and the reason the provider office stated for this, in their cover letter, is "due to audit and review of records for correct coding." Changes were made to diagnoses and chief complaint, but other than saying an addendum was created due to audit & review, there is no other explanation for why diagnoses were changed/added and how can a chief complaint change after several months of the visit, only because records are requested? From what I can see, the patient had come in primarily for her obesity and the addendum makes it look like obesity was incidental and the primary concern was something else. Not just that, its hard to tell exactly what changes were made, from looking at the addendum. I do know that CMS clearly states that the original content cannot be deleted or overwritten, when making amendments. I have asked for clarification and to see the original chart note so I will know exactly what was changed, after I review the document. I do know, like many of you are stating, that modifying or adding to a medical record with the objective of getting paid, is fraudulent, but I can't find a reliable source that explicitly states this. Can someone help? Thank you.
 

csperoni

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Here's the CMS info on fraud and abuse. https://www.cms.gov/Outreach-and-Ed...Products/Downloads/Fraud-Abuse-MLN4649244.pdf Page 12 also has references and links for documentation.

If the record was altered to indicate facts that were not true (regardless of the timing), that to me falls under the False Claims Act. That is an intentional deception.

I would say it's "suspicious" to have a change of chief complaint. It's also suspicious that a provider would even remember the encounter months later. I try my best to stay far, far away from anything suspicious. But if I had a provider who stated they clearly remembered the encounter, and made the changes (after being informed about possible consequences), then as a coder/biller my job is to submit the information by the provider to the payor unless I know it is wrong. If you feel strongly that the provider is doing something clearly wrong, then I suggest notifying compliance. I personally would not involve compliance for a one time "suspicious" issue.

Regarding the addendum/correction/alteration. Before EMRs, the instruction was to put a single line through the incorrect information (so you could still read what was there), write in the correct information, and sign and date the change. With EMRs, any I have used have a specific feature for this. Whether it is a single line cross out, the original record as originally written with an indication there is a corrected record, the original record with a note of the addendum at the top, etc. Once the note is signed, any changes/corrections should be clear. If the note wasn't signed, it shouldn't have been billed out yet since it was not complete. There should also be an audit trail in the EMR.
 

thomas7331

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Maybe it'll help if I give more information - In this case, addendums were created after medical records were requested for review and the reason the provider office stated for this, in their cover letter, is "due to audit and review of records for correct coding." Changes were made to diagnoses and chief complaint, but other than saying an addendum was created due to audit & review, there is no other explanation for why diagnoses were changed/added and how can a chief complaint change after several months of the visit, only because records are requested? From what I can see, the patient had come in primarily for her obesity and the addendum makes it look like obesity was incidental and the primary concern was something else. Not just that, its hard to tell exactly what changes were made, from looking at the addendum. I do know that CMS clearly states that the original content cannot be deleted or overwritten, when making amendments. I have asked for clarification and to see the original chart note so I will know exactly what was changed, after I review the document. I do know, like many of you are stating, that modifying or adding to a medical record with the objective of getting paid, is fraudulent, but I can't find a reliable source that explicitly states this. Can someone help? Thank you.
Christine's post is spot on here. And I agree that there should be an audit trail in the EHR that would show exactly what changes were made, by whom, and when.

I don't think you're going to find a reference telling you this is fraud. Fraud requires intentional misrepresentation of information to obtain payment - it's not illegal or fraudulent for the provider to make corrections and you're not going to find proof of intent to defraud documented - you can only infer it from the patterns you're seeing.

Like Christine is saying, what you are seeing is 'suspicious' - it's evidence but not proof. Only a court can determine that fraud was actually committed or not. That's really the reason payers have these policies that just state clearly that they won't consider late entries as supporting the coding of claims - they can't invest the resources into proving fraud every time there's something suspicious, so to avoid that they just make a blanket reimbursement policy that disallows payment for late documentation. And if they see that a provider is doing this to obtain payment, then they'll start requesting more records as there's a financial incentive for them in doing that. That's a lot more effective than trying to take a provider to court for fraud.
 
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NGS recently released guidelines on how (and how not) to amend records. https://pbn.decisionhealth.com/Blogs/Detail.aspx?id=200953. I think the most common result of an improperly amended record would be a denial on review. Bunches of amended records might be referred to the UPIC, which could trigger a larger audit and if things are really bad, an investigation. Where altering records tends to get physicians in serious trouble is if they alter records after a fraud investigation begins or - as others have noted - it's done to support fraud.



 
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