Amending Medical Records

1. Amendments, Corrections and Delayed Entries in Medical Documentation   
   
   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, Recovery Auditors, SMRC 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, SMRC 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.
    
2. 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, SMRC 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. Clearly identify all original content, without deletion.
   
   Paper Medical Records: When correcting a paper medical record, these principles are generally accomplished by:
    
   1. Using a single line strike through so the original content is still readable, and
   2. The author of the alteration must sign and date the revision.
       

   Amendments or delayed entries to paper records must be clearly signed and dated upon entry into the record. Amendments or delayed entries to paper records may be initialed and dated if the medical record contains evidence associating the provider’s initials with their name. For example, if the initials match the first and last name of the practitioner documented elsewhere in the medical records including typed or written identifying information, the reviewer shall accept the entry.

   Electronic Health Records: Medical record keeping within an EHR deserves special considerations; however, the principles specified above remain fundamental and necessary for document submission to MACs, CERT, Recovery Auditors, SMRC and ZPICs. Records sourced from electronic systems containing amendments, corrections or delayed entries must:
    
   1. Distinctly identify any amendment, correction or delayed entry, and
   2. Provide a reliable means to clearly identify the original content, the modified content, and the date and authorship of each modification of the record.
       
3. If the MACs, CERT, SMRC 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 Regional Office and State Agency.

Related Content

• CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.5 (Amendments, Corrections and Delayed Entries in Medical Documentation)

Posted 2/26/2020