CMS Permits Initials On Amended & Delayed Entries

Posted on Friday, October 9, 2015 2:51 PM

CMS has issued Change Request (CR) 9332, which clarifies that amendments and delayed entities into medical documentation may be initialed and dated rather than signed and dated, which had been CMS’ policy. Upon review, a provider may occasionally discover that certain entries into the medical record at the time of service were not properly documented and need to be amended, corrected, or entered after rendering the service. The CR instructs Medicare contractors to accept confirmation of amendments or delayed entries to paper records that are initialed and dated, if the medical record contains evidence associating the provider’s initials with their name. Click here to read more.

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