General Question for the Week of July 31, 2017

Question:

What Medicare rules must be followed to correct a paper medical record?

Answer:

According to the Centers for Medicare & Medicaid Services (CMS), the following principles apply:

  • Use a single line strike through so the original content is still readable.
  • The author of the alteration must sign and date the revision.

Amendments or delayed entries to paper records must be clearly signed and dated upon entry into the record. They may be initialed and dated if the medical record contains evidence associating the provider’s initials with their name. For example, if the initials match the first and last name of the practitioner documented elsewhere in the medical records including typed or written identifying information, the reviewer shall accept the entry.

Print Friendly, PDF & Email
Facebook
Twitter
LinkedIn

CPT® copyright 2023 American Medical Association (AMA). All rights reserved.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

CPT is a registered trademark of the American Medical Association.

SPRING INTO SAVINGS! Get 21% OFF during our exclusive two-day sale starting 3/21/2024. Use SPRING24 at checkout to claim this offer. Click here to learn more →