tci E/M Coding Alert - 2013 Issue 6

Reader Question: Clearly Document Who Makes Amendments

Question: If and when the patient’s electronic health medical records needs to be corrected/amended/deleted, can anyone (including our biller/coder) do it under the provider’s supervision? Or does the provider have to do the correcting/amending/deleting? South Carolina Subscriber Answer: CMS recently revised its instructions on amending the medical record, but did not specifically say that the original provider has to perform the amendment. According to Transmittal 442, which was updated on Dec. 7, the person who makes the amendment must “clearly indicate the date and author of any amendment, correction, or delayed entry,” and “the...

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