CMS Issues Guidance on Changes to Medical Records

On December 7, 2012 CMS issued Transmittal 442, entitled “Update for Amendments Corrections and Delayed Entries in Medical Documentation”

The CMS transmittal revises the Program Integrity Manual to provide guidance to RACs, ZPICs, MACs and other auditors about what CMS deems is an acceptable Amendment, Correction or Delayed Entry in a patient’s record. Although directed to auditors, the guidance is useful for providers, because it specifically describes what is, and what is not, an acceptable correction to a patient chart.

An issue that providers routinely run into is how do I correct an identified error in a patient’s chart. An identified error in a chart can cause a provider a number of problems, including recoupment of reimbursement to which the provider is entitled. A chart error may be identified in a number of ways, but regardless of how the error is identified, providers must be careful in what actions they take to correct the error.

The guidance starts with the statement that providers are “encouraged to enter all relevant documentation and entries” into the patient’s record at the time the services are provided. This is a clear statement that documentation is expected to be done when care is provided. It is not uncommon for staff to delay completing documentation until, they have finished other tasks, completed a shift, or even later. Failing to complete documentation at the time of service is not only problematic because it does not comply with CMS’ clearly stated expectations, but because an individual who is completing documentation hours, or even days, after providing the care is likely to forget information or to record information that is not accurate.

CMS recognizes that occasionally a provider’s internal audits and other compliance efforts may identify errors in its documentation that require the provider to amend, correct or even add an entry. CMS’ new guidance states that an auditor should only consider corrections, entries and other corrections that meet its defined record keeping principles. The revised manual section then describes these “record keeping principles.”

The described record keeping principles apply whether documentation originates in a paper or electronic record. The guidance states that any corrections, alterations or amendments to a medical record must:

1. Clearly and permanently identify any amendment, correction or delayed entry as an amendment, correction or delayed entry.

2. Clearly indicate the date and author of any amendment, correction or delayed entry.

3. Clearly identify all original content. The original entry must not be deleted.

The revised guidance goes on to describe how these principles apply in the context of both paper records and electronic records.

CMS states that when correcting a paper medical record, the record keeping principles are generally met by using striking through the original content with a single line in a manner that leaves the original content readable. The author striking through the original content should sign and date the alteration. If additions, amendments, or delayed entries are made, these additions should be signed and dated as well. CMS is making it clear that it wants the record to clearly show a correction as such as well as the date on which the correction was made and who made the correction.

This means a correction where an erroneous entry is struck through with a single line and signed and dated by the party correcting the record is acceptable. In contrast, an unsigned and undated note written in the margin of the record will not be accepted. If the unsigned and undated margin note was necessary for the claim, the claim would be denied.

CMS states the same record keeping principles apply to electronic health records, but the guidance does not provide the same level of specificity in this context. Providers who rely upon electronic health records need to consider how their software addresses this issue. If you have to correct an entry, does it keep the original entry? Does it clearly identify it as “original content?” How can you clearly identify your alterations, amendments and corrections as such?

It is extremely important, whether you use paper or electronic records, that you meet these standards. The revised guidance makes it clear that, when reviewing documentation, the auditor may consider altered, amended or corrected documentation that meets these record keeping requirements. It also makes clear that altered, amended, or corrected documentation that does not meet these requirements shall not be considered and will result in a claim denial.

You can find a copy of the OIG report here —>  CMS Transmittal 442

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