May 21, 2024
Apr 15, 2025
Written By Elizabeth Cifers
Medical record amendments are sometimes necessary. While the chart documentation is ideally accurate and correct when signed, mistakes are sometimes found. Amendments are often triggered by payers requesting additional documentation as part of a pre- or post-payment review. Following proper protocol for amending a chart note is crucial in both situations. Keep reading for more information and examples of amendments for retina practices.
Amendments can be late entries, addendums, or corrections. These three types of amendments can be defined as follows:
Late entry – A late entry provides additional information not included in the documentation at the time of the visit.
Addendum – An addendum provides information unavailable at the time of the visit.
Correction – A correction fixes an error in the documentation.1
Corrections should be honest mistakes—the substance of the documentation should not change when a correction is made. For example, a diagnosis code may indicate the incorrect eye. Changing the diagnosis code to indicate the correct eye is an acceptable correction if it is supported in the impression and plan and appropriately annotated.
Perhaps the impression and plan may have discussed a diagnosis, but the diagnosis code is missing. For example, the patient may have macular edema after cataract surgery, for which the physician discussed a possible injection if it doesn’t improve. Still, the physician only indicated the diagnosis code for the post-procedural state. In this case, the biller can ask the physician if they would like to provide the appropriate diagnosis code for the macular edema. A late entry can be made following the proper protocols.
As another example, say the same patient receives an injection, discussed in the impression and plan, but the injection procedure note is not in the final document. However, it can be seen on the ‘back end’ in the electronic health record (EHR) document, but it didn’t make it to the final chart note. When the physician re-saves the chart document to pull the injection procedure documentation into the final chart note, the note should have a correction statement indicating the current date, time, reason for the change, and who made the correction. However, creating the documentation after the fact is prohibited if the injection wasn't documented.
A final example is a diagnostic test, such as a retina OCT, which was billed. Still, the impression and plan did not document or discuss the findings, and the interpretation and report (I&R) wasn’t documented. No matter the circumstance, creating an I&R after the claim is billed or when medical records are requested is the equivalent of creating a falsified medical record.
Many errors and omissions in the chart note are found when an additional documentation request (ADR) arrives from a Medicare Administrative Contractor (MAC). If you’re responding to an additional documentation request (ADR) from a medical reviewer, the letter will include instructions and the timeframe for submission. If you have questions, contact information is included in the ADR letter. Any errors that need an amendment, correction, or late entry must adhere to the guidelines for amending the medical record.
Chapter 3 of the Medicare Program Integrity Manual (Verifying Potential Errors and Taking Corrective Actions) says the following about medical record amendments:
“Regardless of whether a documentation submission originates from a paper record or an electronic health record, documents submitted (…) containing amendments, corrections or addenda must:
1. Clearly and permanently identify any amendment, correction or delayed entry as such, and
2. Clearly indicate the date and author of any amendment, correction or delayed entry, and
3. Clearly identify all original content, without deletion.”
About paper records, the manual says:
“(…) these principles are generally accomplished by:
1. Using a single line strike through so the original content is still readable, and
2. The author of the alteration must sign and date the revision.”
The record may be initialed and dated if the physician’s initials can be associated with their name listed elsewhere in the record.
About EHRs, the manual says:
“Records sourced from electronic systems containing amendments, corrections or delayed entries must:
a. Distinctly identify any amendment, correction or delayed entry; and
b. Provide a reliable means to clearly identify the original content, the modified content, and the date and authorship of each modification of the record.”2
The amendment should include the reason for the additional or corrected information.1
The occasional medical record amendment is to be expected. Understanding the types of amendments and how to amend a medical record appropriately can help you ensure your retina practice is in compliance.
For assistance identifying documentation errors, or better—identifying trends in documentation errors so they can be corrected before they occur—contact consultant Elizabeth Cifers. Elizabeth has been serving in coding and billing roles for decades, including 13 years at a retina practice. She can spot patterns in documentation from a mile away and answer your questions about amending medical records. Additionally, she offers chart audits for retina practices. Schedule a free consultation with Elizabeth here.
Sources:
1Noridian Healthcare Solutions, LCC (2022, October 31). JE Part B: Medical Review: Documentation Guidelines for Amended Medical Records. https://med.noridianmedicare.com/web/jeb/cert-reviews/mr/documentation-guidelines-for-amended-records. Accessed May 14, 2024.
2Centers for Medicare & Medicaid Services (CMS) (2023, May 25). Medicare Program Integrity Manual: Chapter 3 – Verifying Potential Errors and Taking Corrective Actions, Rev. 12056. https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/pim83c03.pdf
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