Medicare Compliance & Reimbursement - 2013 Issue 3
Reader Question: Determine Who Can Perform Record Amendments
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Article Overview
This article answers a compliance-focused reader question about medical record amendments in an electronic health record environment. It discusses federal guidance from CMS and contrasts it with a Medicare contractor’s state-level expectations, making it relevant for providers, billers, coders, compliance staff, and practice managers who handle record integrity and documentation workflows.
Why This Topic Matters
Accurate record amendment processes affect documentation integrity, audit readiness, and policy compliance. Readers need to understand whether broader CMS guidance or more specific contractor/state expectations govern their workflow.
Article Sections
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Question
The reader’s question about who may make changes to an electronic medical record under provider supervision and whether the provider must personally perform them.
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Answer
Discussion of CMS guidance on amendments and a contrasting payer-level policy example, with emphasis on documentation and signature requirements.
What You Will Learn
- How medical record amendment questions are framed in a compliance context
- How federal guidance and payer-specific policies can differ
- Why documentation, dating, and authorship of revisions matter
- Why practices may adopt conservative internal workflows for record changes
Who Should Read This
- Physicians and other providers
- Medical billers and coders
- Compliance staff
- Practice managers
- Health information management professionals
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