Amendments, Corrections and Delayed Entries in Medical Documentation.
Occasionally, certain entries related to services provided are not properly documented and need to be amended, corrected or entered after rendering the service. The MAC’s, CERT, Recovery Auditors, SMRC and ZPIC’s will NOT consider any entries that do not comply with the principles listed below. This includes undated or unsigned entries that are handwritten in the margin of a document.
Recordkeeping Principles Regardless of whether a documentation submission originates from a paper record or an electronic health record, documents submitted to MACs, CERT, Recovery Auditors, SMRC and ZPICs containing amendments, corrections or addenda must:
Clearly and permanently identify any amendment, correction or delayed entry.
Clearly indicate the date and author of any amendment, correction or delayed entry.
Clearly identify all original content, without deletion.
When correcting a Paper Medical Record, these principles are generally accomplished by:
Using a single line strike through so the original content is still readable.
The author of the alteration must sign and date the revision.
Amendments or delayed entries to paper records may be initialed and dated if the medical record contains evidence associating the provider’s initials with their name.
For example, if the initials match the first and last name of the practitioner documented elsewhere in the medical records including typed or written identifying information, the reviewer shall accept the entry.
When correcting an Electronic Health Record, amendments, corrections or delayed entries must:
Distinctly identify any amendment, correction or delayed entry.
Provide a reliable means to clearly identify the original content, the modified content, and the date and authorship of each modification of the record.