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?

South 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, 2012, the person who makes the amendment must “clearly indicate the date and author of any amendment, correction, or delayed entry.” For paper records, the transmittal says “the author of the alteration must sign and date the revision.” For electronic records, it says the record must provide “a reliable means to clearly identify the original content, the modified content, and the date and authorship of each modification of the record.” It doesn’t say specifically that the provider has to be the one doing the amending, just that the author of the amending must be clearly identified either by his or her signature (paper record) or some other means (electronic record). You can read the transmittal at www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R442PI.pdf.

With that in mind, however, some Medicare administrative contractors (MACs) may have more specific requirements. For instance, a MAC may ask that the practitioner must sign and date the correction. Therefore, to stay on the safe side, most practices do ask the original provider to make the amendment.