Revised Policy of CMS: Amendments, Corrections and Delayed Entries in Medical Documentation

Revised Policy of CMS: Amendments, Corrections and Delayed Entries in Medical Documentation

Sagar Shetty

1/16/2013

Dear List,

I just found the latest revision in the policy for acceptance of medical
documentation by MAC's, CERT, RAC, and ZPIC on the CMS website and I
thought of sharing it with the list, even though some of you must be
already aware of this. This new revision is effective from 01/08/13.
Below is the revision in the policy:

3.3.2.5 - Amendments, Corrections and Delayed Entries in Medical
Documentation
(Rev. 442, Issued: 12-07-12, Effective: 01-08-13, Implementation:
01-08-13)
This section applies to MACs, CERT, Recovery Auditors, and ZPICs, as
indicated.

A. Amendments, Corrections and Delayed Entries in Medical Documentation
Providers are encouraged to enter all relevant documents and entries
into the medical record at the time they are rendering the service.
Occasionally, upon review a provider may discover that certain entries,
related to actions that were actually performed at the time of service
but not properly documented, need to be amended, corrected, or entered
after rendering the service. When making review determinations the MACs,
CERT, Recovery Auditors, and ZPICs shall consider all submitted entries
that comply with the widely accepted Recordkeeping Principles described
in section B below. The MACs, CERT, Recovery Auditors, and ZPICs shall
NOT consider any entries that do not comply with the principles listed
in section B below, even if such exclusion would lead to a claim denial.
For example, they shall not consider undated or unsigned entries
handwritten in the margin of a document. Instead, they shall exclude
these entries from consideration.

B. 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, 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. Not delete but instead clearly identify all original content

Paper Medical Records: When correcting a paper medical record, these
principles are generally accomplished by using a single line strike
through so that the original content is still readable. Further, the
author of the alteration must sign and date the revision. Similarly,
amendments or delayed entries to paper records must be clearly signed
and dated upon entry into the record.

Electronic Health Records (EHR): Medical record keeping within an EHR
deserves special considerations; however, the principles wed above
remain fundamental and necessary for document submission to MACs, CERT,
Recovery Auditors, and ZPICs. Records sourced from electronic systems
containing amendments, corrections or delayed entries must:

a. Distinctly identify any amendment, correction or delayed entry, and
b. Provide a reliable means to clearly identify the original content,
the modified content, and the date and authorship of each modification
of the record.

C. If the MACs, CERT or Recovery Auditors identify medical documentation
with potentially fraudulent entries, the reviewers shall refer the cases
to the ZPIC and may consider referring to the RO and State Agency.



Here is the link for the entire policy with the new revisions:

<URL Redacted>
 

Hope this helps!

Sagar Shetty
Prosthetist/Orthotist
Office Manager

Bionic Prosthetics & Orthotics
8695 Connecticut Street, Ste E
Merrillville, Indiana 46410
e. <Email Address Redacted>