Making Late Entries, Addendums, and Corrections to the Medical Record Warrants a Proactive Strategy

Late entries, addendums, or corrections should never be common occurrences.

Medicare coverage guidelines dictate that physician notes are required for support of medical necessity, and this documentation must be available to the Medicare Administrative Contractor (MAC) upon request. It is strongly recommended that medical practices use proactive strategies to educate your physicians and non-physician providers about the requirements outlined in Medicare’s Policy Manual regarding medically necessary documentation, but also how to apply addendums or late entries, to ensure that the notes and documentation in your patient’s chart, whether electronic or paper, are accurate and relevant.

First, create a Medicare assessment tool (based on an NCD or LCD) that specifies what documentation Medicare requires to consider a medical service medically appropriate.

• If the tool is for reasonable and necessary durable medical equipment (DME) consideration, such as an orthotic or prosthesis,, provide it to your referring physicians. This tool can also helpful to orthotists and prosthetists as they prepare their documentation.
• Have a scrubbing protocol to review documentation prior to claim submission to ensure that when addendums are necessary, they will be acceptable. For example, if documentation is missing or does not support the device or service, an addendum should be requested from the physician. A valid addendum must be received before the claim is submitted.
• When a physician’s corroborating notes are unsatisfactory and requests for additional information fail to deliver the required documentation, you could not only lose billed revenue, but out-of-pocket costs if you are using purchased services and equipment for DME. It is imperative that staff are trained on documentation protocols.

However, what happens when the proactive approach does not work? While corrections to medical records should be avoided, whenever possible, it cannot always be avoided.

When a deficiency is discovered in a provider’s notes, it is common practice to create a late entry or an addendum, or make a minor change to the medical record. It is important to know how to correctly make the changes, but first, it is important to know the difference between a late entry and an addendum:

A late entry is made to the medical record when information that was absent from the original entry is recorded after the original note was created, dated, and signed, and possibly billed to a payer.

An addendum to a medical record provides additional information that was not available at the time of the original entry. Addendums are typical for contracts to efficiently update terms and conditions. However, creating an addendum to a patient’s medical record has specific rules that must be followed to avoid potential inference of a fraudulent note. Addendums made after the claim is submitted will not be considered when Medicare reviews the medical record.

When amending the medical record, the following guidelines should be followed:

•  Clearly identify whether the entry is a late entry or an addendum.
•  Enter the additional information as additional information. Do not make it appear that the information you are adding was part of the original document.
  •  Enter the date of the late entry or addendum.
  •  The late entry or addendum must be signed.
  •  Identify the original content.
  •  Make sure the late entry or addendum does not override the original entry.
  •  If you were not the author of the original entry, note that you confirmed the late entry or addendum with the original author. (It is not recommended that ancillary staff enter addendums for physician notes. It should come from the original provider for best practices.)
  •  Note the justification for the modification.

Late entries, addendums, or corrections should never be common occurrences, as they could be seen by Medicare as evidence of inadequate practices, so it is important to review your documentation for accuracy and ensure that correct and complete information is entered.

A best practice should always be to take proactive approaches to obtain compliant medical records, but when noncompliant records are received, it is important to have compliance guidelines for treating late entries, addendums, and corrections to avoid unnecessary losses.

I would start with the Medicare Program Integrity Manual. It is clear, concise, and a good place to start your compliance workflow on this important aspect of clinical documentation integrity.

Programming Note: Listen to Terry Fletcher report this subject live today during Talk Ten Tuesday, 10-10:30 a.m. EST.