Amending Medical Records

What You Need to Know

Both physicians and prosthetists/orthotists must document their services in the beneficiary's medical record at the time the services are rendered. If they notice an error or missing information after the entry is signed and published, the provider can add an addendum, correction, or delayed entry to the medical record. The Medicare Program Integrity Manual outlines "widely accepted Recordkeeping Principles" and explains how to properly document these changes in order to be considered a valid part of the medical record:

1. Clearly and permanently identify any addendum, correction or delayed entry as such.
2. Addendum: provides information that was not available at the time of the original entry and typically expands upon information that is already provided in the medical record.
3. Correction: revises an error in the medical record.
4. Delayed Entry: provides additional information that was omitted from the original entry. Unlike an addendum, a delayed entry adds brand new information that was not previously discussed in the medical record.
5. Clearly indicate the current date and author of the addendum, correction, or delayed entry
6. Sign and date all changes to the medical record.
7. Clearly identify all original content, without deletion.
8. Paper Medical Records: Draw a single line through the incorrect information so the original content is still legible.
9. Electronic Medical Records: Clearly identify both the original content and the modified content.

What this Means for You

All changes to the medical record must follow these documentation guidelines. It is not only important to follow this protocol when adding addendums/corrections to your notes, but also when requesting an addendum from the referring physician. Medical records that do not follow these guidelines are considered invalid. This not only increases the chances of a denied prior authorization request, but also puts the claim at risk of recoupment during an audit after the device is already delivered and paid for. The Medicare Program Integrity Manual specifically states, "MACs, CERT, Recovery Auditors, SMRC, and UPICs shall NOT consider any entries that do not comply with the principles […], even if such exclusion would lead to a claim denial." 

Whenever possible, you should justify the reason for an addendum, correction, or delayed entry to validate the change in the medical record. If the original progress note fails to make any mention of the service, the changes may be suspect and not given much weight or credibility. In this scenario, amending the medical records is not appropriate. Instead, you and/or the physician need to document the new information during a follow-up visit with the patient. It is also important to complete all addendums, corrections, and delayed entries within a timely manner from the original entry. Although Medicare does not establish a specific timeframe in which you can or cannot make these changes, you should only add them if you have total recall of the information you are changing. After an extended period of time has passed, it is much more difficult to remember everything that happened at the original appointment. Again, instead of amending the medical records in this situation, the patient needs to be scheduled for a new appointment.

If you are using electronic medical records, it is also important to understand how to be compliant with the "Recordkeeping Principles" within your own EMR system. As stated above, the original content must always be visible when making a change to the medical record. Unlike paper records, most EMR platforms do not allow for a strikethrough when correcting a previous entry, so it is important not to permanently delete any information. Instead, your EMR system should have the ability to track any changes to an entry after it was published/signed, and the original entry should still be available for review. The amended record needs to be clearly flagged to indicate that it was changed, and if anything was removed, a protocol should be put in place to retain and easily access copies of the original content. 

For more information on amending medical records, see Section 3.3.2.5 of the Medicare Program Integrity Manual.