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Providers should not erase/replace when they update a chart

Your clinicians can make amendments, corrections and late entries to their records, but a recent email from National Government Services (NGS) reminds practices that there’s a right way and a wrong way to go about it.
And the wrong way could lead to an overpayment demand during an audit, the March 16 notice states.
The alert from NGS – the Part B Medicare Administrative Contractor (MAC) for 10 states – uses guidance from IOM 100-08, chapter 3, § and notes the same basic rules apply whether your practice uses paper charts, an EHR or a combination of the two.
When the provider changes the record, they must clearly indicate:
  1. What they changed.
  2. The nature of the change: amendment, correction or late entry.
  3. Who made the change. The practitioner can sign the change or use his initials if their first and last name is available in the record.
  4. The date of the change.
Just as importantly, the practitioner should not permanently delete or obscure any information from the record. For example, to indicate a deletion in a paper chart the practitioner should strike through the text with a single line. The text should still be legible to a reviewer. Obliterated sections and white out can be signs that the record was falsified according to IOM 100-08, chapter 3, §3.3.2.
Changes that don’t follow the guidelines will be ignored during a review and that could spell bad news for the claim. Auditors “shall not consider any entries that do not comply with the principles … even if such exclusion would lead to a claim denial,” the notice states.
Blog Tags: CMS
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