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Printed Date: 9/22/2015
Providers are encouraged to enter all relevant documents and entries into the medical record at the time they are rendering the service. Occasionally, upon review a provider may discover that certain entries, related to actions that were actually performed at the time of service but not properly documented, need to be amended, corrected or entered after rendering the service.
Recordkeeping Principles Widely Accepted
Regardless of whether a documentation submission originates from a paper record or an electronic health record, documents containing amendments, corrections or addenda must:
Documentation should not be added to meet billing requirements. For further information regarding entries in medical records (amendments, corrections and addenda) please visit the CMS Program Integrity Manual (Pub. 100-08) (PDF, 598 KB), Chapter 3, Section 220.127.116.11.
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Last Updated: 07/01/2019