The van Halem Group Offers Advice on Do’s and Don’ts for Amending a Medical Record

Home Blog The van Halem Group Offers Advice on Do’s and Don’ts for Amending a Medical Record

An additional service available to EW members, the van Halem Group offers professional guidance on audits, appeals, compliance, enrollment, education and other complex issues. One of these issues include explaining 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 a list of ‘Do’s and Don’ts’ to assist you in this particular situation.  

Do: 

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, practitioners are encouraged to follow the fundamental standards. 

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. 

Read the full list of Do’s and Don’ts’ from the van Halem Group here

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