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

2014-07 Electronic Health Records and Addenda Issue

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LEEDerGroup.com

July 24, 2014

Electronic Health Records and Addenda

Joint DME MAC Publication

  • Recent DME MAC claim review experience has highlighted an issue with electronic health records (EHR) and documentation of additional clinical information that occurs following the initial beneficiary visit. The Centers for Medicare & Medicaid Services (CMS) refers to this additional information as amendments; however, similar principles as discussed below apply to corrections and delayed entries. Suppliers of durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) must be mindful of the record keeping principles detailed below when providing records during the course of an audit request. Specifically, suppliers must ensure that if providing a medical record that has been amended or corrected, that the original medical record note is also provided to the requesting entity.
  • The Medicare Program Integrity Manual (Internet-only Manual 100-08), Chapter 3, Section 3.3.2.5 provides the following guidance on amendments, corrections and delayed entries:Regardless of whether a documentation submission originates from a paper record or an electronic health record, documents submitted to MACs, CERT, Recovery Auditors, 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. Not delete but instead clearly identify all original content.

  • The above record keeping principles apply to all medical records, whether electronic or handwritten; however, the Program Integrity Manual also specifically addresses amendments, corrections and delayed entries in EHRs with the following instructions:
  • Medical record keeping within an EHR deserves special considerations; however, the principles above remain fundamental and necessary for document submission to MACs, CERT, Recovery Auditors, 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.
  • The manner in which an EHR system notates amendments and corrections can differ by software vendor; therefore, suppliers of (DMEPOS) must be careful when preparing their response to a record request and provide both the original record and any amendments that were made to the original note. Often in reviewing claim documentation, the Medical Review staff receives only the amended record with no indication of what was amended or corrected, when the change occurred or by whom the change was made. Failure to provide the complete record or a record with changes inconsistent with the CMS manual instructions may result in claim denial.