CMS has issued a transmittal amending the Medicare Program Integrity Manual that contains guidelines providers must follow when making amendments, corrections and delayed entries to patient medical records.  Providers may make changes to a medical record subsequent to a patient encounter so long as the provider:

  1. Clearly and permanently identifies that any amendment, correction or delayed entry is in fact a subsequent change;
  2. Indicates the date and author of the amendment, correction or delayed entry; and
  3. Does not delete, but instead identifies, original content contained in the medical record.

To the extent that providers must change information contained in a paper record, providers should use a single line strike through the original content so that it remains legible.

The transmittal acknowledges that edit functions in an electronic health record may not be universal, but makes clear that all changes must adhere to the general principles of clearly identifying subsequent changes and not removing original content.

The transmittal directs Medicare Administrative Contactors, Recovery Audit Contractors and other reviewers to accept “all submitted [medical record] entries that comply with” the principles set forth in the transmittal.  If a provider makes amendments to a medical record that are not in compliance with the transmittal, CMS instructs reviewers to disregard such amendments.

The instructions appear in the Program Integrity Manual (CMS Pub. 100-08), Ch. 3, §, and is available here.