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altering pt records

  1. #1
    Location
    Seacoast- Dover New Hampshire
    Posts
    609
    Default altering pt records
    Medical Coding Books
    I would like a link that states you cannot alter the pt records for convience. A couple of examples:
    1) Pt requests physical, coded and billed as such, ins rej as PE allowed every 2 yrs and this is pt responsibility. Pt does not want to pay, asks the MD to change the Medical Record so the ins will cover the office vsit. Note states Pt her for physical and follow up of other chronic problems.
    2) Pt comes in for "medicare checkup", first line of note states here for comprehensive physical, enctr states 3 dx with 99397. Pt wants us to reword the note so they don't have to pay.
    I feel that the medical record is a permanent and should not be altered. Need to have this in writing to prove a point. Thanks for your help in advance.
    Karen Barron, CPC
    Hampton New Hampshire Chapter

  2. #2
    Location
    Seacoast- Dover New Hampshire
    Posts
    609
    Default
    I am hoping the CMS has something.
    Karen Barron, CPC
    Hampton New Hampshire Chapter

  3. #3
    Location
    Seacoast- Dover New Hampshire
    Posts
    609
    Default
    Any takers on this scary subject?
    Karen Barron, CPC
    Hampton New Hampshire Chapter

  4. #4
    Default
    You are correct, you can't alter a record for patient convience. That would be fraud. Give me a few minutes and I will see what I can find. I have found this before.

    The patient has the right to look at their medical record and request errors be corrected, they do not have the right to tell a provider to make up a completely different note so they don't have to pay for a service they requested.

    Hopefully I can find a link soon,

    Laura, CPC

  5. #5
    Location
    North Carolina
    Posts
    3,126
    Default
    Examples of Medicare Fraud

    Altering claim forms, electronic claim records, medical documentation, etc., to obtain a higher payment amount.........


    http://www.cms.hhs.gov/manuals/downloads/pim83c04.pdf

    4.2.1

  6. #6
    Location
    Seacoast- Dover New Hampshire
    Posts
    609
    Default
    Thank you Rebecca for the link.
    Karen Barron, CPC
    Hampton New Hampshire Chapter

  7. #7
    Default
    I see Rebecca had the CMS link but I thought this was very interesting so I am posting it as well.

    http://www.vamedmal.com/faqs/how-can...al-records.cfm

    Q: How can we prevent the doctor from altering my medical records?

    A: We really can't. But the penalties are sever if they get caught.

    First, their insurance company may drop them altogether.

    If a doctor alters your medical record they can lose their medical license. The Department of Medicine takes those charges very seriously. If we are able to prove through the course of your case that the physician altered records, then that doctor is in for a very rough ride.

    If a hospital alters a record, they can be fined or sanctioned. In addition, if a hospital or doctor cannot locate important relevant documents and records in your case, there are instances where Courts have granted judgment to the injured victim simply because the hospital or doctor could not provide a valid explanation of where those records are now. In most cases, those records would be needed to prove plaintiff's case. Without those records, the victim is at a distinct disadvantage in being able to prove their case. If the Court agrees that those documents have been lost, misplaced, or intentionally misplaced, then they have the ability to find in favor of the plaintiff, and direct that a trial be held solely on the damages the victim has suffered.


    Laura, CPC

  8. #8
    Location
    Charleston, South Carolina
    Posts
    641
    Default
    Just one more comment. When a patient requests to review his record, you may want to sit with him while he does his review. We had a patient in a practice several years ago who requested to review his chart. The doctor said no problem and we handed the patient the chart and he sat in the waiting room reading it. Little did we know, he was crossing things out and rewriting them as he had a "difference of opinion" I guess than what the doctor wrote. This man didn't give any hint of having a complaint, just very nicely called and ask to review his record. He handed the record back, said thanks and left. The nurse noticed all the writing when she checked the record prior to filing it. Our doctor dictated a note for the chart explaining the situation. Fortunately, you could still read everything he "crossed" out and rewrote. Lesson learned. Pt never commented on chart, so the office really doesn't know why he did this. Never had any issues afterward either. Just an FYI here.
    Machelle Morningstar, CPC, COC, CEMC, COSC
    AHIMA Approved ICD-10-CM/PCS Trainer

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