E/M Coding Alert - 2013 Issue 1
Industry Notes:
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Article Overview
This industry note summarizes CMS guidance on post-service medical record corrections, amendments, and documentation integrity. It is relevant to providers, coders, compliance staff, and auditors who need to understand the general documentation expectations and how amended records may be evaluated during review. The article also notes CMS instructions to MACs and auditors regarding referral of suspected fraud-related documentation concerns.
Why This Topic Matters
Accurate record amendment practices affect compliance, audit readiness, and the credibility of clinical documentation. Understanding the broad CMS documentation framework helps practices preserve original entries while making legitimate corrections in a way that can be reviewed by auditors.
What You Will Learn
- How CMS discusses amendments and corrections to medical records after service is rendered
- General expectations for preserving original documentation when making changes
- What auditors are told to consider when reviewing amended entries
- How CMS addresses documentation concerns that may suggest fraud
Who Should Read This
- Medical coders
- Compliance staff
- Healthcare providers
- Practice managers
- Auditors
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