One of the things home health and hospices frequently have issues with is physician signatures. Often the issues surround the physician not dating their signature or making changes on hard copy documents where it is not identifiable who made the changes.
On October 2, 2015, CMS released Change Request 9332 to update the Medicare Program Integrity Manual. This change request implementation date is November 2, 2015. It covers the issue of late entry of corrections to a medical record:
Section 18.104.22.168 – Amendments, Corrections and Delayed Entries in Medical Documentation
B. Recordkeeping Principles
Regardless of whether a documentation submission originates from a paper record or an electronic health record, documents submitted to MACs, CERT, Recovery Auditors, and ZPICs containing amendments, corrections or addenda must:
- Clearly and permanently identify any amendment, correction or delayed entry as such, and
- Clearly indicate the date and author of any amendment, correction or delayed entry, and
- Clearly identify all original content, without deletion.
Paper Medical Records: When correcting a paper medical record, these principles are generally accomplished by:
- Using a single line strike through so the original content is still readable, and
- The author of the alteration must sign and date the revision.
Amendments or delayed entries to paper records must be clearly signed and dated upon entry into the record. Amendments or delayed entries to paper records may be initialed and dated if the medical record contains evidence associating the provider’s initials with their name.
The update, basically, instructs the MACs, CERT, RAs & ZPICs to accept late entries and amendments with initials and date, as long as the initials are identified with the signer’s name. Plans of Care are probably the most common document that physicians like to edit by crossing out something or crossing out and replacing….this can only happen if initialed and dated. Note that the last statement in the update above would allow for a full late entry document to be initialed and dated only!