decisionhealth Newsletters, Coder Pink Sheets - 2013 Issue 1 (January)
APCPS Briefs
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Article Overview
This article summarizes CMS guidance on preserving and identifying amendments, corrections, and delayed entries in patient medical records across paper and electronic formats. It is relevant to providers, practices, and agencies that need to understand documentation integrity expectations and how Medicare review contractors may evaluate revised records.
Why This Topic Matters
Documentation changes can affect whether Medicare reviewers consider an entry during claim review, so understanding CMS recordkeeping expectations is important for compliance and claim support.
What You Will Learn
- How CMS expects amendments, corrections, and delayed entries to be identified in medical records
- What recordkeeping principles apply to both paper records and EHRs
- How Medicare review contractors may treat revised entries during claim review
- Why documentation integrity matters for claim support and reimbursement
Who Should Read This
- Physician practices
- Home health agencies
- Medical coders
- Medical billers
- Compliance staff
- Health information management professionals
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