Chart audits have revealed that some providers are altering medical records inappropriately. CMS reminds physicians not to alter the documentation after a request for records has been received.
Improper altering often fails into two categories:
- Records that have been altered inappropriately to conform to the dates of service requested in the audit.
- Information has been added inappropriately to the record.
CMS’ Program Integrity Manual — Chapter 4, Section 4.2.1 — states that altering documentation may be construed as fraudulent behavior, if it is not done following the appropriate steps.
To make corrections while maintaining the integrity of medical records, be sure to:
- Mark through the original entry with one line. The original entry should still be legible. Initial the marked-through entry and date the entry.
- Enter the corrected information. Initial and date the corrected entry also, so that there is no question as to when the correction was made.
- If you are only adding information, mark the date you added the information and initial the entry.
According to the Program Integrity Manual, "Providers have an obligation, under law, to conform to the requirements of the Medicare program. Fraud committed against the program may be prosecuted under various provisions of the United States code and could result in the imposition of restitution, fines and, in some instances, imprisonment. In addition, there is also a range of administrative sanctions (such as exclusion from participation in the program) and civil monetary penalties that may be imposed when facts and circumstances warrant such action."
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About the author: This article was adapted from the June 2009 Coding Bulletin, written by AAOE coding executive Sue Vicchrilli, COT, OCS.