CMS Permits Initials on Amended and Delayed Entries
October 9, 2015 11:39 AM
The Centers for Medicare and Medicaid Services (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.
Occasionally, upon review a provider may 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 the 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.
To view the CR click here.