Dos and Don’ts of Amending the Anesthesia Record
The anesthesia record, like medical records in general, should be complete and accurate at the time when the physician signs it—ideally. In practice, it occasionally requires amendment. Given the huge role that accurate documentation plays in our medical payment system, compliance with the rules and regulations governing medical record amendments is important. Altered medical records have great potential for fraud, especially if the added information helps to raise the level of a billable service, and no one should be surprised if auditors look at any changes closely.
One basic principle was added to the first paragraph of the provision that regulates amendments in Chapter 3 of the Medicare Program Integrity Manual, Section 3.3.2.5, when that provision was updated effective October 2, 2015. The intent of the new paragraph is to make it clear that amendment should be the exception.
All services provided to beneficiaries are expected to be documented in the medical record at the time they are rendered. Occasionally, certain entries related to services provided are not properly documented. In this event, the documentation will need to be amended, corrected, or entered after rendering the service.
Section 3.3.2.5 further sets forth three “Recordkeeping Principles” that practices must follow in submitting amended documents to their Medicare carriers or auditors, and these apply to both paper and electronic health records (EHRs). Documents containing amendments must:
- Clearly and permanently identify any amendment, correction or delayed entry as such, and
- Clearly indicate the date and author of any amendment, correction or delayed entry, and
- Clearly identify all original content, without deletion.
The Program Integrity Manual provision elaborates on paper vs. EHRs:
Paper Medical Records: When correcting a paper medical record, these principles are generally accomplished by:
- Using a single line strike through so the original content is still readable, and
- 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. Amendments or delayed entries to paper records may be initialed and dated if the medical record contains evidence associating the provider’s initials with their name.
Electronic Health Records (EHR): Medical record keeping within an EHR deserves special considerations; however, the principles specified above remain fundamental and necessary for document submission to MACs, CERT, Recovery Auditors, and ZPICs. Records sourced from electronic systems containing amendments, corrections or delayed entries must:
- Distinctly identify any amendment, correction or delayed entry, and
- Provide a reliable means to clearly identify the original content, the modified content, and the date and authorship of each modification of the record.
There are three legitimate types of amendment to a medical record: late entries, addenda and corrections. As explained on the website of Noridian Healthcare Solutions, the Medicare Administrative Contractor (MAC) for a number of Western states, the purposes and some particulars of the three types are:
Late Entry: A late entry supplies additional information that was omitted from the original entry. The late entry bears the current date, is added as soon as possible, is written only if the person documenting has total recall of the omitted information and signs the late entry.
Example: A late entry following treatment of multiple trauma might add: "The left foot was noted to be abraded laterally. John Doe MD 06/15/09"
Addendum: 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.
Example: An addendum could note: "The chest x-ray report was reviewed and showed an enlarged cardiac silhouette. John Doe MD 06/15/09"
Correction: When making a correction to the medical record, never write over, or otherwise obliterate the passage when an entry to a medical record is made in error. Draw a single line through the erroneous information, keeping the original entry legible. Sign or initial and date the deletion, stating the reason for correction above or in the margin. Document the correct information on the next line or space with the current date and time, making reference back to the original entry.
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. (Emphasis in original.)
The following, on the other hand, are examples of amendments that may be considered deliberate falsification of medical records, a felony offense:
- Creation of new records when records are requested
- Back-dating entries
- Post-dating entries
- Pre-dating entries
- Writing over, or
- Adding to existing documentation (except as described in late entries, addendums and corrections)
A question that arises frequently concerns the timeliness of amendments to medical records. The Program Integrity Manual is oddly silent on the issue. Accordingly, physicians and their staff should complete any amendments in a reasonable time frame.
In brief, addenda, delayed entries or corrections to the medical or anesthesia record on which a Medicare claim is based must make it clear that they are created after the record is completed—that they are amendments. The must also clearly indicate their date and their author, and they "must clearly identify all original content, without deletion.” They should not be made routinely and generally they should be made only within a reasonable period after the date of service.
Hospitals and health systems may have their own policies and requirements, which physicians on the medical staff should also respect. We are not aware of any published private payer policies on medical record amendments but it is hard to imagine that they would be more rigorous than Medicare’s. In the interest of as much simplicity as possible, it might be best to follow Section 3.2.2.5 of the Program Integrity Manual for all payers.