Author: Tony Mira
What happens when you make a mistake in your medical record documentation? Do you just write over it or, in the EMR context, simply hit delete and reenter? What about the timing of the revision? All these and other topics related to revising the anesthesia record are discussed in today’s article.
In November of 1948, editors of the Chicago Daily Tribune published the results of the U.S. presidential election under a bold front-page headline that read: “Dewey Defeats Truman.” The only problem is that, to my recollection, we have never had a President Dewey. The newspaper was so sure that New York Governor Thomas E. Dewey would win in a walk that they prematurely published the headline before all the results were in—in part because an impending local printer’s strike forced the paper to go to print hours before they normally would have. Oops.
Nobody’s perfect. We’re all prone to making mistakes. No matter how careful we are to get it right, to think before we act, to avoid error, at some point we’re going to blow it. It is part of the human condition to occasionally fail; and that tendency toward imperfection often finds its way onto the medical record. In our audits of thousands of anesthesia records over the years, we inevitably find incorrect entries, missing data, incomplete descriptions and conflicting information. A mistake has been made. So, what do you do now?
Avoidance is Not an Option
The one thing you don’t want to do when faced with an errant record is to ignore it. For purposes of clinical practicality and claim acceptability, it is incumbent upon you to ensure the information is complete and accurate. When we receive your record, our coders and data entry staff review it to glean data that will ultimately be used in the claim submission process. Whenever the information on the record raises a question, our staff will try to find information from other medical records to determine the intent of the entry on the anesthesia record. For example, if there is a question about your documentation of the surgical procedure or diagnosis, our staff may be able to find clarifying information on the surgeon’s report.
However, there are times when accessing other records to fill in the information gap is either unachievable due to technical hindrances or is inappropriate due to compliance constraints. When this occurs, or when there is a clear error or critical omission on the anesthesia record (e.g., no provider signature), then our team will send out a request to the provider to correct or appropriately complete the record. That request is referred to as a “provider return” (PR) or “information request” (IR). It is important that you respond to these requests as soon as possible, since a delay in processing your claim may hold up an entire batch of records.
The Correct Way to Correct
One cannot go about revising the record in a haphazard or arbitrary way. There are certain rules that the Centers for Medicare and Medicaid Services (CMS) has implemented that thoroughly address corrections of, and additions to, the medical record. Let’s take a look at the rules that would be most applicable to anesthesia record revisions.
Let’s say you’re working with a hard-copy (non-electronic) record. You later discover that you inadvertently wrote down a start time of 0944 when you actually meant to write down the correct start time of 0844. Medicare rules are clear. Do not obliterate the incorrect information. Instead, draw a single line through the errant entry and, just above it or adjacent to it, enter in the correct time. You will then need to sign the new entry, providing also the date of the correction next to the signed correction. If you have already signed the record, then you need only initial the corrected entry, assuming your initials comport with your signature.
If you failed to enter a data element critical for billing (e.g., anesthesia time, physical status, anesthesia type, ancillary procedure), you can go back and enter that information—but only if you have sufficient recollection of the information. You can’t enter a “guesstimate.” The rules generally indicate that late entries of missing information should be made within a short timeframe. Here’s how one of the Medicare Administrative Contractors (MACs) put it: “The late entry bears the current date, is added as soon as possible, is written only if the person documenting has total recall of the omitted information and signs or initials the late entry.”
A couple of weeks ago, we talked about the rules for provider signatures. If you failed to provide your signature, you can go back and sign it within a short span of time. Well, what does that mean? A 2018 Medicare Learning Network (MLN) article from CMS stated the following:
You may not add late signatures to orders or medical records (beyond the short delay that occurs during the transcription process). Medicare does not accept retroactive orders. If your signature is missing from the medical record (other than an order), you may submit an attestation statement. Your contractor may offer specific guidance regarding signature attestation statements, including whether current laws or regulations allow attestation for missing signatures in certain situations.
Does this instruction deal only with post-submission signature additions? Does it definitively preclude adding a missing signature prior to the claim being submitted to the payer? The only thing that seems clear from the above excerpt is that there is a period during which a late signature can, in fact, be added, i.e., during “the short delay that occurs during the transcription process.” Well, there is no transcription process when it comes to anesthesia records. So, what is the window of time anesthesia providers have to add a missing signature? How long is the typical transcription process? The timing of adding a missing signature will be left to the provider’s discretion, as long as (a) you believe you are complying with the intent of the above MLN language, and (b) the missing signature is added prior to the claim being submitted.
If the record is reviewed by Medicare and the payer determines it is not legible, you will be given the opportunity to send Medicare a signature log or a signed statement attesting to the fact that the signature on the record in question is yours and was signed by you. A signature log is a typed listing of physicians and/or non-physician practitioners identifying their names with a corresponding handwritten signature.
As to electronic medical records (EMRs), it’s going to be rather difficult to draw a line through an incorrect entry. Since there are functionality hurdles that come into play when using an EMR, the Medicare Program Integrity Manual (MPIM), provides the following guidance:
Records sourced from electronic systems containing amendments, corrections or delayed entries must: (a) Distinctly identify any amendment, correction or delayed entry; and (b) Provide a reliable means to clearly identify the original content, the modified content, and the date and authorship of each modification of the record.
Trouble with Triplicates
Some practices that use paper records are completing an anesthesia record that comes in a triplicate format: one for medical records, one for the pharmacy and one for the provider. So, that raises the question: when a revision is needed, must all three be revised? We raised this question with the Office of Inspector General (OIG) some years ago. Their staff attorney advised that the OIG has taken no position on this and that interested individuals should direct that particular inquiry to their local MAC. One of these MACs, in weighing in on this question, suggested that corrections should be made on the hospital’s part of the triplicate only, but that a progress note containing the revision, as well as the date and author of the revision, should be sent to the pharmacy and the provider to attach to their own part of the triplicate record.
Making mistakes is unpleasant for all of us; but, in the context of medical record mishaps, we have the opportunity and the duty to correct them.