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Linda Collins Blogger

Addendums to Physician Notes

Posted by Linda Collins | December 04, 2015

When the physician documentation is not substantial enough to support medical necessity of a particular device, can the doctor make changes to the notes?

The initial answer would be "yes," but with caution.   Physicians may make changes to their progress notes as long as the physician is clarifying, expanding or correcting information that was obtained during the evaluation.  Chapter 3 of the Program Integrity Manual allows for the addition of amended, corrected or late entries by the physician.  The manual says "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."  My warning in using an amendment or late entry is the information must relate to information that is already documented.  The purpose of the amendment is to correct documentation about a service that was provided during the evaluation.  If the original progress note fails to make any mention of the service, the addition of the amendment may be suspect and may not be given much weight or credibility.

For instance, if the original progress note says "The beneficiary is expected to be able to return to taking care of his animals with a proper prosthesis."   When reading the progress note, one may ask what does this really mean, and what type of activities does this really require?  In my opinion it would be acceptable for the physician to amend the note to explain what was meant by "take care of the animals."  Let's say the beneficiary lived on a farm and was responsible for daily feeding and care of 10 cows.  The physician could amend the progress note and explain what type of animals the beneficiary is caring for, and what type of activities the beneficiary must complete to provide daily feeding and care of the cows. 

The point I am trying to make is a physician should only be adding an amendment or additional information based upon the services the physician actually performed during the evaluation.  If the physician did not actual provide the service and obtain the information during the evaluation, the physician should not add the information to a prior progress note as an amendment. 

Region D, Noridian Q&A Session for Lower Limb Prosthesis Coverage, December 2013, said it best when answering whether an amendment was permissible.  According to Noridian, "The important thing to remember is that the addendum reflects actions that were actually performed; requesting a physician to amend a record to meet criteria would never be appropriate."

I always ask, did the physician actually discuss or learn this information from the evaluation?  If yes, then it would be proper to add to the progress note as an amendment. If the information was not obtained or discussed during the evaluation, then I do not recommend using an amendment as a manner of documenting the new information.

If I understand you correctly, physician can use the amendment as a way to provide further documentation of the services provided during the specific evaluation.  Are there any rules on how the amendment is to be documented in the medical record?

The Medicare Program Integrity Manual (PIM), Chapter 3, Section – Amendment, Corrections and Delayed Entries in Medical Documentation, provides specific guidance outlining the documentation requirements for adding an amendment.  According to the PIM, the progress notes containing the amendment, correction or late entry must meet the following three requirements: (1) the documentation must clearly and permanently identify the amendment, correction or delayed entry; (2) the documentation must clearly identify the date and author of any amendment, correction or delayed entry; and (3) all original content must be maintained without deletion.  These requirements are called the "Recordkeeping Principles."

The physician, whether electronic or paper records, must clearly indicate an amendment is being added.  The best practice is for the physician to start the new entry with the title "Amendment."  Using a title for describing the new information will ensure compliance with the first Recordkeeping requirement.  The new entry must also be dated by the physician.  For paper records, the physician must sign (or initial if the medical record provides a way to associate a physician's initials with his/her name) and date the new entry.  While initials can be used in certain circumstances, I always recommend a signature over an initial if the medical record is handwritten (i.e. a paper record).  For an electronic record, the entry must include a way to identify the author of the amendment.  Most electronic medical records include an entry listing the author and date of the entry.  I also always recommend reviewing the electronic signature entry to ensure the physician has reviewed and signed the amendment record.  If the electronic signature is dated prior to the addition of the amendment, best practices is to request the physician to review and add a new signature to the electronic medical record dated on or after the addition of the amendment.

If the amendment is not properly added to the medical record by following the Recordkeeping Principles, the information in the amendment may not be considered by the auditor.  The information in the amendment will only be considered as part of the medical record when the physician fully complies with the Recordkeeping Principles outlined above.

Will we be flagged for audits if we use addendums as our corroborating documentation?

​The use of amendments alone will not "flag" or trigger CMS or its contractors to perform additional audits.  Amendments are permitted and acceptable means of documenting information within the medical record.  If a physician uses the amendment process as it is intended to be used to further explain what services and information were completed during the evaluation, and the physician follows the Recordkeeping Principles when adding the amendment to the original progress note, the use of the amendment will not lead to any additional auditing activity.

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