tci Part B Insider - 2015 Issue 44

Reader Question: Don't Take Chart Amendments Lightly

Question: One of our physicians made mistakes on several charts and printed out new documentation to replace the old notes. Our office manager isn’t comfortable with this. Can you advise? Answer: Although it is legal to amend your records, you cannot simply throw out the original documentation and replace it with something new, because payers could consider that “record tampering.” As long as the doctor actually remembers the information, or reads notes or other written information that triggers their memory of the additional information, he can add information at any time. Follow these steps to make...

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