Contrary to popular belief, you can sometimes make amendments to medical documentation after the date of service, as long as you know the rules. The key is to ensure you’re following payer regulations, state laws and internal compliance guidelines that your practice has in place. As long as you check those boxes, amending the medical record can paint a clearer picture of the patient’s situation and what the doctor did during the visit.
Check out five essential factors to keep in mind when you’re amending medical records.
1. Never Amend Records Just to Get Paid
Some practices will receive a claim denial, realize that the claim didn’t meet the payer’s guidelines, and then amend the record to fit the payment criteria. This is not a sufficient reason for amending documentation. Instead, you should only change the medical record when the provider realizes they omitted important information from the record that would help guide future treatment decisions.
2. Identify Amendments Clearly
When you’re amending medical records, you should never simply delete the old record and add a new one. Instead, you should cross out or otherwise mark the previous documentation that you’re hoping to correct, and then clearly identify what you’re adding in its place. Essentially, you must still be able to read the old documentation and the new notations.
3. Sign and Date the Late Entry
CMS guidelines indicate that you must “clearly indicate the date and author of any amendment, correction or delayed entry.” Therefore, whoever adds the amendment should sign and date it. It’s also a good idea to put a title on the amendment, such as “June 14, 2022, amendment to record.” This way, you’re ensuring that no one reading it would think it was part of the original note. If you have a reason for the amendment, you should add that as well.
4. Make the Amendment as Soon as Possible
If the provider realizes that an amendment is necessary, they should create it as soon as possible rather than waiting. Auditors would need to believe that the provider truly remembered the details that they’re adding after the fact, and it would be hard to prove that you remembered something from a year or so ago, unless the patient’s situation was very much out of the ordinary.
5. Amend All Copies: Paper and Electronic
If you documented a visit in the electronic health record (EHR) and then printed out hard copies of the documentation, make the amendment on both the EHR and the hard copy versions. This way, no matter where your provider or an auditor looks, they’ll have the corrected and true version of the notes.
Check This Sample Amendment
To ensure you’re amending medical records properly, consider this example of an updated medical record:
Original Note:
Saw Mrs. Smith on August 1 for follow-up to bilateral conjunctivitis. Her condition has improved, and I advised her to discontinue the eyedrops and to call me if the symptoms return.
Signed,
Dr. Albert Jones, August 1, 2022.
Amended Note:
Saw Mrs. Smith on August 1 for follow-up to bilateral conjunctivitis in the right eye (bolded text added Aug. 3, 2022). Her condition has improved, and I advised her to discontinue the eyedrops and to call me if the symptoms return.
Signed,
Dr. Albert Jones, August 1, 2022.
Amendment added August 3, 2022: Today I realized that the documentation indicated that Mrs. Smith’s conjunctivitis affected both eyes, and corrected the documentation to indicate that it only affected her right eye. This amendment was made today by me.
Signed,
Dr. Albert Jones, August 3, 2022
Want to know more details about amending medical records? Sign up for the online training, “Persuade Payers to Pay up With Successful Appeals Process.” During this one-hour session, expert Kelly Grahovac, MBA, will walk you through the details of how to create an addendum to a medical record to ensure it’s compliant. Sign up today!
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