LEEDer Group Inc.
8508 North West 66th St.
Miami, Florida 33166 USA

Phone: 305.436.5030
Fax: 305.436.0086
E-mail Address: info {at] LEEDerGroup [dot] com

2012-03 Medical Record Amendments; Medicare Guidelines

Jurisdiction 11 Part B Medical Record Amendments
  • Medicare guidelines require complete and appropriate documentation that is adequate and legible to ensure proper payment. Timely, accurate and complete documentation is important for the review of medical records. All medical record entries must be dated and signed in a timely manner.
  • After the medical record entries have been dated and signed, additional information may be added to a medical record in the form of an appropriate addendum. Addenda should only be necessary on rare occasions and should not be used in a common practice of documenting services performed. Amending medical records to meet policy guidelines is inappropriate.
  • Palmetto GBA has identified the following criteria that will be accepted as an appropriate addendum to medical records:
    The addendum must be added to the medical record in a timely manner within a few days of the original entry.
    The addendum must contain individualized, patient-specific clinical information for each date of service amended. We do not accept blanket statements, declarations or attestations.
    The addendum should be chronological in the original medical records. If the addendum is voluminous, you may refer in the progress notes to the addendum information found elsewhere in the records.
    Each addendum must be legible, signed and dated by the person making the entry.
  • The addendum should address additional, clinically relevant information; not information just to meet regulatory requirements or to later validate a CPT code that was initially down coded due to lack of supporting documentation.
  • When making a correction to the medical record, legal requirements must be followed. Never write over, erase or obliterate an entry to the medical record. A single line should be drawn through the incorrect information, and the correction should be written near the deletion. The incorrect information should still be legible. The practitioner should sign and date the deletion. A correction can also be made by submitting the original record and adding the correction(s) as an addendum, preferably typed, with a full explanation of why the record was in error. The practitioner should sign and date the correction.

last updated on 03/09/2012