October 01, 2017
Area(s) of Interest: Electronic Health Records Health Information Technology Payor Issues and Reimbursement Practice Management
CPR’s “Coding Corner” focuses on coding, compliance and documentation issues relating specifically to physician billing. This month’s tip comes from Diane Barton, AAPC Fellow, and G. John Verhovshek, the managing editor for AAPC, a training and credentialing association for the business side of health care.
Occasionally, providers must correct a medical record, or otherwise amend it to add detail. The Centers for Medicare and Medicaid Services (CMS) and other payers acknowledge the need for such addendums. CMS includes addendum guidelines in the Medicare Program Integrity Manual, Chapter 3, Section 3.2.5 (“Amendments, Corrections and Delayed Entries in Medical Documentation”):
Providers are encouraged to enter all relevant documents and entries into the medical record at the time they are rendering the service. Occasionally, upon review a provider may discover that certain entries, related to actions that were actually performed at the time of service but not properly documented, need to be amended, corrected, or entered after rendering the service…. 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. Not delete but instead clearly identify all original content
Government and third-party payers recommend that each office or organization develop an internal policy regarding addendums. Noridian (Medicare Part B contractor for Jurisdiction E, which includes California) publishes instruction on its website that provide an excellent basis for such a policy.
Amended Medical Records
Late entries, addendums or corrections to a medical record are legitimate occurrences in documentation of clinical services. A late entry, an addendum or a correction to the medical record bears the current date of that entry and is signed by the person making the addition or change.
Late Entry: A late entry supplies additional information that was omitted from the original entry. The late entry bears the current date, is added as soon as possible, and is written only if the person documenting has total recall of the omitted information and signs or initials the late entry.
Example: A late entry following treatment of multiple trauma might add: “The left foot was noted to be abraded laterally. John Doe M.D. 06/15/09”
Addendum: An addendum is used to provide information that was not available at the time of the original entry. The addendum should also be timely and bear the current date and reason for the addition or clarification of information being added to the medical record and be signed or initialed by the person making the addendum.
Example: An addendum could note: “The chest X-ray report was reviewed and showed an enlarged cardiac silhouette. John Doe M.D. 06/15/09”
Correction: When making a correction to the medical record, never write over, or otherwise obliterate the passage when an entry to a medical record is made in error. Draw a single line through the erroneous information, keeping the original entry legible. Sign and date the deletion, stating the reason for correction above or in the margin. Document the correct information on the next line or space with the current date and time, making reference back to the original entry.
Correction of electronic records should follow the same principles of tracking both the original entry and the correction with the current date, time, reason for the change and initials of person making the correction. When a hard copy is generated from an electronic record, both records must be corrected. Any corrected record submitted must make clear the specific change made, the date of the change and the identity of the person making that entry.
Source: Documentation Guidelines for Amended Medical Records
Note that only the attending provider—that is, the provider who saw the patient and documented the initial note for the visit in question—may amend the medical record.
Occasionally, a provider may receive a query for additional information in the medical record. Per AHIMA’s “Guidelines for Achieving a Compliant Query Practice:”
The generation of a query should be considered when the health record documentation:
- Is conflicting, imprecise, incomplete, illegible, ambiguous or inconsistent
- Describes or is associated with clinical indicators without a definitive relationship to an underlying diagnosis
- Includes clinical indicators, diagnostic evaluation, and/or treatment not related to a specific condition or procedure
- Provides a diagnosis without underlying clinical validation
- Is unclear for present on admission indicator assignment
The AHIMA guidelines further state, “To support why a query was initiated, all queries must be accompanied by the relevant clinical indicator(s) that show why a more complete or accurate diagnosis or procedure is requested.”
Queries may take several forms (e.g., open-ended, multiple choice, or yes/no), but in no case may they “lead” the provider. AHIMA guidelines clarify, “A leading query is one that is not supported by the clinical elements in the health record and/or directs a provider to a specific diagnosis or procedure.” Additionally, queries should not question the provider’s clinical judgment, and should not indicate the potential financial impact of the response.
For example, at checkup a diabetic patient complains of numbness in his feet. The provider assesses the patient and documents, “Diabetes unspecified, uncontrolled” and “Neuropathy in both feet: To podiatry for consult.” In such a case, an appropriate query may state, “If the etiology of the neuropathy of the patient’s feet can be further specified, please document this in the progress note.” By contrast, it would be inappropriate for the query to state, “Confirm that neuropathy is due to diabetes.”