License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

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POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

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Documentation Requirements: Principles of Documentation Questions & Answers (Q&As)

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When a medical record has been amended or corrected, is there a time limit as to when a practitioner must complete an addendum to his/her original notes?
- CMS has not set any specific timelines for documentation corrections. If a practitioner needs to correct a medical record, they must follow the amendment and corrections instructions. Our Signature Attestation Statement guide outlines these instructions.
  
  Regardless of whether a documentation submission originates from a paper record or an electronic health record, documents submitted to MACs, Comprehensive Error Rate Testing (CERT), Recovery Auditors, SMRC, and Unified Program Integrity Contractors (UPICs) containing amendments, corrections, or addenda must:
  - Clearly and permanently identify any amendment, correction, or delayed entry as such
  - Clearly indicate the date and author of any amendment, correction, or delayed entry
  - Clearly identify all original content, without deletion
  Originally published: 07.31.2020
  Revised: 11.05.2025
Are the notes from the nursing home acceptable as part of the medical record?
- Yes. The Standard Documentation Requirements for All Claims Submitted to DME MACs states: In the event of a claim review, information contained directly in the contemporaneous medical record is the source required to justify payment except as noted elsewhere for prescriptions and CMNs. The medical record is not limited to treating practitioner’s office records but may include records from hospitals, nursing facilities, home health agencies, other healthcare professionals, etc. (not all-inclusive).
  
  Originally published: 07.31.2020
  Reviewed: 11.05.2025
If the provider signs the medical record electronically, can the date be handwritten?
- No; dates and signatures should be in the same format. Providers using electronic systems need to recognize that there is a potential for misuse or abuse with alternate signature methods. For example, providers need a system and software products that are protected against modification, etc., and should apply adequate administrative procedures that correspond to recognized standards and laws.
  
  Originally published: 07.31.2020
  Reviewed: 11.05.2025
Do the medical records to support medical necessity have to be from the same practitioner who signed the standard written order (SWO)?
- For items other than power mobility devices (PMDs) that appear on the Required Face-to-Face Encounter and Written Order Prior to Delivery List, the treating practitioner that conducted the face-to-face encounter does not need to be the prescriber for the DMEPOS item. However, the prescriber must:
  - Verify that a qualifying face-to-face encounter occurred within the 6 months prior to the date of their prescription
  - Have documentation of the qualifying face-to-face encounter that was conducted
  Originally published: 07.31.2020
  Reviewed: 11.05.2025
If documents are scanned into electronic form, do I need to keep hard copies for seven years?
- No, you do not need to keep printed copies of documentation that is maintained electronically. The Medicare program does not have requirements for the media formats for medical records. However, the medical record needs to be in its original form or in a legally reproduced form, which may be electronic, so that medical records may be reviewed and audited by authorized entities. Providers must have a medical record system that ensures that the record may be accessed and retrieved promptly. Documentation must be maintained in the supplier's files for seven years from date of service (DOS).
  Originally published: 07.31.2020
  Reviewed: 11.05.2025

License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

AMA Disclaimer of Warranties and Liabilities.

CMS Disclaimer

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

Documentation Requirements: Principles of Documentation Questions & Answers (Q&As)

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