Whether you document in an electronic medical record (EMR), on paper, or dictate your notes, most likely, you have made an error in your documentation and/or omitted documentation in the medical record for that treatment visit. When this occurs, the Centers for Medicare and Medicaid Services (CMS) has provided instructions on record keeping principles, whether you document on paper or in an EMR.
Per CMS, documents submitted to MACs, CERT, Recovery Auditors, SMRC and UPICs, whether paper or EMR, containing amendments, corrections or addenda must:
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This article is not intended to and does not serve as legal advice or as consultative services, but is for general information purposes only.