Pathology/Lab Coding Alert

Follow new CMS guidelines when you must make changes.

Pretty much every pathologist has faced this scenario: You look over your report only to realize that you left out some important information.

Now when you face this situation, you’ll have some new direction from CMS, according to Transmittal 442.

Strive for Completeness

CMS encourages providers to "enter all relevant documents and entries" into the record at the time of service, but notes that "occasionally, upon review a provider may discover that certain entries, related to actions that were actually performed at the time of service but not properly documented, need to be amended, corrected, or entered after rendering the service."

Survive audit: If an auditor ever reviews your files, CMS directs them to consider your amended entries -- but only if you follow the rules. For instance, auditors "shall not consider undated or unsigned entries handwritten in the margin of the document," the Transmittal advises.

Do this: When adding, correcting, or entering information after the date of service, you should identify it as an amendment, and the practitioner should sign and date it. Never delete the original entry -- instead, ensure that all original content is identifiable. You can do this on a paper record by using a single strike line through the original content. For an EHR, you must "provide a reliable means to clearly identify the original content, the modified content, and the date of authorship of each modification of the record," CMS says in the transmittal.

CMS advises MACs and auditors that see potential fraud in the documentation to refer those cases to the ZPIC auditors. To read the complete transmittal, visit www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R442PI.pdf.