This page from Noridian covers Documentation Guidelines for Amended Medical Records. Please use it for reference.
Topics include:
Elements of a Complete Medical Record
Amended Medical Records
- Late Entry
- Addendums
- Corrections
Falsified Documentation
This includes the creation of new records at the time records are requested
- Back-dating entries
- Post-dating entries
- Pre-dating entries
- Writing over, or
- Adding to existing documentation (except as described in late entries, addendums and corrections)
https://med.noridianmedicare.com/web/jeb/cert-reviews/mr/documentation-guidelines-for-amended-records
[Jurisdiction E - Medicare Part B]
JE Part B / Medical Review / Documentation Guidelines for Amended Records
Disclaimer: This guidance is to be used for an easy reference; the ICD-9-CM and ICD-10-CM code books and the Official Guidelines for Coding and Reporting are the authoritative references for accurate and complete coding. This blog may contain references or links to statutes, regulations, or other policy materials. It is not intended to take the place of either the written law or regulations. The information presented herein is for general informational purposes only and is accurate as of the date of publication.
Topics include:
Elements of a Complete Medical Record
Amended Medical Records
- Late Entry
- Addendums
- Corrections
Falsified Documentation
This includes the creation of new records at the time records are requested
- Back-dating entries
- Post-dating entries
- Pre-dating entries
- Writing over, or
- Adding to existing documentation (except as described in late entries, addendums and corrections)
https://med.noridianmedicare.com/web/jeb/cert-reviews/mr/documentation-guidelines-for-amended-records
[Jurisdiction E - Medicare Part B]
JE Part B / Medical Review / Documentation Guidelines for Amended Records
Disclaimer: This guidance is to be used for an easy reference; the ICD-9-CM and ICD-10-CM code books and the Official Guidelines for Coding and Reporting are the authoritative references for accurate and complete coding. This blog may contain references or links to statutes, regulations, or other policy materials. It is not intended to take the place of either the written law or regulations. The information presented herein is for general informational purposes only and is accurate as of the date of publication.
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