Do’s and Don’ts: Amending a signed and dated Legal Document

By: Nancy Conant, Clinical Consultant

Are you finding yourself challenged explaining how to properly amend the record to a therapist or practitioner, particularly when the document has been previously signed?

DO

The proper way to amend a Licensed Certified Medical Professional Specialty Evaluation and Face to Face Mobility Examination is to strictly adhere to CMS’s established recordkeeping principles.  An addendum to a legal document needs to be added as soon as possible and contain all clarification information intended to support medical necessity.  When amending a LCMP Specialty Evaluation and Face to Face, there are fundamental standards you can recommend the therapist and/or the practitioner follow:

  • Clearly identify the date of the original date of the LCMP/LMN or F2F. Example:  Addendum to the LMN/F2F dated 3/16/17
  • Include the beneficiary’s name
  • The author must clearly sign and date the addendum
  • For Power Mobility Devices, a practitioner must sign/date/concur

When a significant amount of information is to be added to a previously signed/dated LCMP/LMN or Face to Face that clarifies coverage criteria and/or accessory justification, the best way to keep the validity of the current LCMP/LMN/F2F and the date sequence of other required documentation intact is to prepare a separate document for the addendum.  Most addendums are prepared to clarify information already entered in the medical documentation provided in the review.  These clarifying addendums do not change the completion date of the F2F, therefore, a new 7EO, F2F, or DPD is generally not needed if the addendum is executed correctly and timely.

Don’ts

  • Therapists/Practitioners often make the mistake of adding the addendum information to the existing documentation as if they were creating the document for the first time. This is tantamount to altering a legal document and is not acceptable practice.  This is a source of Medicare denial.
  • Do not re-sign an original document that has already been signed unless you provide an explanation for re-signing the document. Forcing the dates is not acceptable practice.
  • Back dating a record is not acceptable practice
  • Pre/Post-dating an addendum or record is not acceptable practice

In summary, LCMP/LMN and Face to Face addendums that have been properly amended will be considered by the Medicare reviewer when determining coverage criteria has been met for certain DME products.