For reasons of compliance, whenever this is the discovery for a need to make a correction, addition, deletion, addendum, or other change, that will involve billing – charges, claim submission or resubmission, reviews, audit requests, etc. – and this request is being made after the physician has already signed the record for the day in question, the requested change must receive the authorization of the physician of record.
The format of the request should be as follows:
The person requesting the change should address their email to the physician of record. The request should include the specific changes that are desired and the reason(s) why the changed is required.
The following people should be copied on the request: CEO, Billing Lead and Medical Records Lead. Once the physician agrees to the changes – or denies the request, or suggests and/or requests other edits by email, it is the Medical Records Lead who will effect the necessary changes to the record. She will subsequently email all affected parties when her changes have been implemented so that our billing staff can take those steps needed to accomplish their tasks.
If appropriate, such requests for changes may be shared with technical staff for training/quality assessment and improvement purposes.
Closely following this policy is essential from a compliance standpoint as the OIG and CMS are placing much greater emphasis on the review of chart edits going forward due to the increasing adoption of EMR Systems.