Medicare Requirements for Medical Record Addenda
Last Friday, CMS issued Transmittal R442PI which clarifies the requirements necessary for amendments, corrections and late entries to the medical record to be considered by Medicare contractors during medical review. Medicare contractors that review records for payment determinations include the Medicare Administrative Contractors (MACs), Comprehensive Error Rate Testing (CERT), Recovery Auditors (RAs or RACs) and Zone Program Integrity Contractors (ZPICs).
Providers are encouraged to enter all relevant documents and entries into the medical record at the time they are rendering the service. If actions that were actually performed were not properly documented at the time of the service, a correction, amendment or late entry is acceptable for Medicare review only if it adheres to the following standards:
- Any amendment, correction or late entry shall be clearly and permanently identified as such,
- The date and author must be clearly identified, and
- Original content must also be clearly identified and not deleted.
These requirements apply to both paper and electronic medical records.
Corrections to paper medical records require that:
- The original content is still readable which can be accomplished by using a single line strike through
- The author of the alteration sign and date the revision
- Amendments or late entries be clearly signed and dated upon entry into the medical record.
Acceptable revisions in an electronic record must:
- Distinctly identify any amendment, correction or delayed entry, and
- Provide a reliable means to clearly identify the original content, the modified content, and the date and authorship of each modification of the record.
The requirements note that Medicare reviewers shall exclude from consideration undated or unsigned entries handwritten in the margin of a document. The manual also warns against potentially fraudulent entries.
Article by Debbie Rubio