Medicare Compliance & Reimbursement

Hint: Clear and concise documentation and timeliness are key components.

If you’re confused about how to make additions to your patients’ medical records, one Medicare Administrative Contractor (MAC) has some handy advice.

MAC Noridian Healthcare Solutions defines a record addendum, saying “An addendum is used to provide information that was not available at the time of the original entry. The addendum should also be timely and bear the current date and reason for the addition or clarification of information being added to the medical record and be signed by the person making the addendum” (emphasis original).

Noridian cautions that anyone making changes to a physical medical record, even to make addenda that are serving as corrections, should not “write over or otherwise obliterate” the passage or entry to the medical record.

As for electronic records, the same principles apply.

“Correction of electronic records should follow the same principles of tracking both the original entry and the correction with the current date, time, reason for the change and initials of person making the correction. When a hard copy is generated from an electronic record, both records must show the correction. Any corrected record submitted must make clear the specific change made, the date of the change, and the identity of the person making that entry,” Noridian says (emphasis original).