Inpatient Facility Coding & Compliance Alert

Question: If and when the patient’s electronic health medical records needs to be corrected/amended/deleted, can anyone (including our biller/coder) do it under the provider’s supervision? Or does the provider have to do the correcting/amending/deleting?

North Carolina Subscriber

Answer: CMS recently revised its instructions on amending the medical record but did not specifically say that the original provider has to perform the amendment.

According to Transmittal 442, which was updated on Dec. 7, the person who makes the amendment must “clearly indicate the date and author of any amendment, correction, or delayed entry,” and “the author of the alteration must sign and date the revision.” It doesn’t say specifically that the provider has to be the one doing the amending, just that the author or the person doing the amending must sign it. You can read the transmittal at http://www.cms.gov/site-search/search-results.html?q=Transmittal 442.

With that in mind, however, other states have more specific requirements. For examples, a practitioner in the state of South Carolina is required to sign and date the correction, so it appears that the practitioner should be the person making the change. Other states may have a similar requirement. Therefore, to stay on the safe side, most practices and hospitals do ask the original provider to make the amendment.