Skip to Main Content

Print | Bookmark | Font Size: + | –

Physician Orders/Altering Medical Records

March 30, 2009 the Centers for Medicare and Medicaid Services (CMS) issued the following JSM (JSM/TDL-09225, 03-26-09):

Recently the Department of Health and Human Services' Office of Inspector General (OIG) conducted an evaluation of the Comprehensive Error Rate Testing (CERT) Review Contractor. As a result of this OIG review, we have concluded that the provision in the Program Integrity Manual (PIM) that has come to be known as the "clinical review judgment" provision is confusing and contradicts itself in parts.

The language, in part, currently reads:

"While MR staff must follow national coverage determinations and local coverage determinations, they are expected to use their expertise to make clinical judgments when making medical review determinations. They must take into consideration the clinical condition of the beneficiary as indicated by the beneficiary's diagnosis and medical history when making these determinations. "

This confusion has created different interpretations of when it is appropriate for Contractor Review Staff to use clinical review judgment. Therefore, CMS will clarify the PIM to be explicit that clinical review judgment may not override statutory, regulatory, ruling, national coverage decision or local coverage decision provisions and that all documentation and policy requirements must be met before clinical review judgments applies. We expect to release this PIM clarification shortly.

This JSM does not change IOM Pub 100-2, Ch 15, sect 80.6 et sub. concerning physician's signatures, when requesting an order for labwork, CERT must have one of the following:

  1. An office note where the ordering physician wrote which labs were to be performed this must be signed, dated, and contain a notation that this is a late entry if appropriate; the signature and date must be legible.
  2. A requisition signed, dated and if appropriate contain a notation that this is a late entry by the ordering physician; the signature and date must be legible.

Keep in mind that medical records cannot be altered.

  • Errors must be legibly corrected so that the reviewer can draw an inference as to their origin. These corrections or additions must be dated, preferably timed, legibly signed and contain a notation that this is a late entry.
  • All entries must be legible to another reader to a degree that a meaningful review can be conducted.
  • If the signature is not legible and does not identify the author, a printed version should also be recorded.
  • Addition of a missing signature must be treated as a late entry, the correction or addition must be dated, preferably timed, legibly signed and contain a notation that this is a late entry.

Every note stands alone, i.e., the performed services and necessary signatures must be documented at the outset. Delayed written explanations will be considered for purposes of clarification only. They cannot be used to add and authenticate services billed and not documented at the time of service or to retrospectively substantiate medical necessity. For that, the medical record must stand on its own with the original entry corroborating that the service was rendered and was medically necessary.

spacer

26 Century Blvd Ste ST610, Nashville, TN 37214-3685 © CGS Administrators, LLC. All Rights Reserved