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By Kim Turner RN, Clinical Consultant, The van Halem Group

Just a quick review, the medical record is a subset of documents and data that you, the supplier, maintain relevant to a Medicare beneficiary.  Generally, the medical record documents/data are necessary to:

  • document the beneficiary’s health and healthcare
  • provide a means for communication between practitioners caring for the beneficiary
  • provide a basis for evaluating adequacy and appropriateness of care
  • support claims for payment or reimbursement
  • protect legal interests of beneficiary and provider
  • provide clinical data for planning, research and education

All services provided to beneficiaries are expected to be documented in the medical record at the time they are rendered. Occasionally, certain entries related to services provided are not properly documented. In this event, the documentation will need to be amended, corrected, or entered after rendering the service.

When making review determinations the MACs, CERT (Comprehensive Error Rate Testing), Recovery Auditors (RAC), and UPICs shall consider all submitted entries that comply with the widely accepted record keeping principles described below.  The MACs, CERT, Recovery Auditors, and UPICs shall NOT consider any entries that do not comply with these principles, 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.

In all cases, regardless of whether the documentation is maintained or submitted in paper or electronic form, any medical records that contain amendments, corrections, or addenda must:

  • Clearly and permanently identify any amendment, correction, or delayed,
  • Clearly indicate the date and author of any amendment, correction, or delayed entry, and
  • Not delete, but instead, clearly identify all original content.

Corrections to Paper Records

  • Use a single line strike through the error so that the original content is still readable, and
  • The author of the alteration must document his/her signature (or initials) and date next to the correction, and
  • Amendments or delayed entries to paper records must be clearly signed and dated upon entry into the record.

As a reminder, please do not complete a correction by over-writing and do not use correction tape or white-out correction fluid to amend a medical record as these practices do not comply with the standard Medicare record keeping principles. Also, a reminder that you do not use a high-light marker to identify information in the electronic or paper record as the area high-lighted will be altered (dark/blacked out) when the document is faxed or scanned. 

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