van Halem Group

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By Donna Youngblood RN, BSN, CPC

Do you find it difficult to explain to your referral source how to properly amend a patient's medical record, particularly after the document has been signed? The van Halem Group is aware of this challenge and has provided some guidance to assist you in this particular situation. Take a look at this helpful list of 'Do's and Don'ts' below.

The proper way to amend any progress note is to strictly adhere to the CMS’s established recordkeeping principles. An addendum to a legal document needs to be added as soon as possible and contain clarification information intended to support medical necessity. When amending a note, there are fundamental standards you can recommend that the practitioner follow. These include:

Clearly identifying the date of the original note. Example: Addendum to the F2F dated 3/16/17
Include the beneficiary’s name
The author must clearly sign and date the addendum
For Power Mobility Devices, a practitioner must sign/date/concur

When information is to be added to a previously signed/dated progress note that clarifies coverage criteria and/or accessory justification, the best way to keep the validity of the current note is to prepare a separate document for the addendum OR add to the end of the document. Most addendums are prepared to clarify information already entered in the medical documentation provided in the review.

Don’t

Practitioners often make the mistake of adding the addendum information to the existing documentation as if they were creating the document for the first time. This is tantamount to altering a legal document and is not an acceptable practice. This often results in a denial by Medicare.
Do not re-sign an original document that has already been signed unless you provide an explanation for re-signing the document. Forcing the dates is not an acceptable practice.
Back dating a record is not an acceptable practice
Pre/Post-dating an addendum or record is not an acceptable practice

In summary, addendums that have been properly amended will be considered by the Medicare reviewer when determining coverage criteria has been met for certain DME products.