CMS released Transmittal 442, Change Request (CR) 8105 on December 7th. It provides instructions to Medicare contractors regarding amended, corrected, and delayed entries in medical records. This updates the CMS Medicare Program Integrity Manual, Section 126.96.36.199 effective January 8, 2013.
According to this Change Request, the MACs, CERT, Recovery Auditors, and ZPICs are instructed NOT to consider entries that don’t comply with recordkeeping principles, even if exclusion of an entry will result in a claim denial.
In the manual update, “providers are encouraged to enter all relevant documents and entries into the medical record at the time they are rendering the service.” However, the policy goes on to acknowledge that there may be occasions when documentation was not completed or completed properly and may need to be amended. Medicare contractors are told that they are to consider all submitted entries that comply with the widely accepted Recordkeeping Principles, but NOT consider any entries that do not comply with the principles.
Recordkeeping principles for record amendments apply to both paper and electronic medical records. These principles include:
- Clearly and permanently identify any amendment, correction or delayed entry as such;
- Clearly indicate the date and author of any amendment, correction or delayed entry;
- Not delete but instead clearly identify all original content.
When correcting a paper medical record, the “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.”
CMS acknowledges that although “record keeping within an EHR deserves special considerations” the same principles apply. EHR corrections or delayed entries 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 manual update also states “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”.
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