By: Cindy Triplett, CPC, CANPC, CPMA
Senior Director, Anesthesia Education
Have you ever finalized a medical record and realized you forgot pertinent information? Maybe you neglected to document the diagnosis or omitted essential details of the care provided. Here at Ventra Health, it’s not unusual that we encounter notes that are missing information needed for billing. Regardless of who noticed it first, or what was omitted, an amendment, correction, or a delayed entry to the record will be needed.
The process of making these updates can be quite challenging for many providers. In addition to CMS guidelines, facilities may have additional criteria for amending records. Adhering to these processes is critical to ensure compliance with all regulations. Ventra offers the following advice to assist providers in remaining consistent with these standards.
First and foremost, once a provider has determined the need for an amendment, correction, or addition, the change must be completed in a timely manner. Secondly, edit the information using techniques specific to the type of record. Changes to paper medical records are handled differently than those made to an Electronic Health Record. Regardless of the type of record, it’s important to understand that hiding or obstructing the original content is prohibited.
The Centers for Medicare and Medicaid Services (CMS) clarified their instructions for amending or correcting medical record entries in their Publication 100-08, Medicare Program Integrity, Transmittal 732. CMS states that 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:
1. Clearly and permanently identify any amendment, correction, or delayed entry as such, and
2. Clearly indicate the date and author of any amendment, correction, or delayed entry, and
3. Clearly identify all original content, without deletion
Ventra has created the table below to further illustrate the concepts:
| Paper Medical Records | Electronic Health Records | |
|---|---|---|
| Corrections | 1. Single strike through the original text so it remains legible 2. The alteration must be signed and dated by the author. | 1. Distinctly label the correction 2. Provide a reliable means to clearly identify the original content, the modified content, and the date of authorship of each correction |
| Amendments or Delayed Entries | 1. Sign and date upon entry into the record Can be initialed and dated if the medical record contains a method to associate the provider’s initials with their full name. | 1. Distinctly label the updated information 2. Provide a reliable means to clearly identify the original content, the modified content, and the date of authorship of each modification |
Ventra encourages providers to work with your Health Information Management (HIM) staff to ensure they are meeting their medical record obligations.
Although it is always best to complete an accurate record from the start, errors and omissions will happen. Just make sure you handle them correctly to lessen challenges under audit. Also, remember to submit medical record updates to your billing partner as changes may impact code selection for the claim(s).
What’s Next and How Ventra Health Can Help
Ventra Health takes compliance very seriously. Our Provider Education team has launched this Compliance Blog Series to help you navigate the complexities of compliance and coding changes. In case you missed it, check out our other posts in the series.
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