Practicefirst would like to share with you information posted on the National Government Services (NGS) website regarding Amendment of Medical Records.
Occasionally, certain entries related to services provided are not properly documented and need to be amended, corrected or entered after rendering the service. The MAC’s, CERT, Recovery Auditors, SMRC and ZPIC’s will NOT consider any entries that do not comply with the principles listed below. This includes undated or unsigned entries that are handwritten in the margin of a document.
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:
Clearly and permanently identify any amendment, correction or delayed entry.
Clearly indicate the date and author of any amendment, correction or delayed entry.
Clearly identify all original content, without deletion.
For Compliance questions, please contact Becky Amann at 716-389-3202 or email@example.com.