Outpatient Facility Coding Alert - 2012 Issue 44
Physician Note: Use 'Single Line Strike to Amend Medical Record, CMS Says
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Article Overview
This article covers CMS guidance on how physicians and other providers should amend or correct medical records after service has been rendered. It is aimed at Part B practices, compliance staff, and billing/coding professionals who need to understand documentation maintenance expectations, audit considerations, and related CMS transmittal updates.
Why This Topic Matters
Proper record amendments can affect documentation integrity, audit response, and compliance risk for physician practices. The article also flags a CMS update that practices may need to incorporate into their recordkeeping procedures.
What You Will Learn
- How CMS frames post-service documentation amendments and corrections
- What general documentation integrity expectations apply to amended records
- How paper records and electronic records are treated differently at a high level
- How auditors are directed to evaluate amended entries and related concerns
Who Should Read This
- Physicians
- Part B practices
- Medical coders
- Billing staff
- Compliance staff
- Audit and documentation teams
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