Department of Health & Human Services (DHHS) Centers for Medicare & Medicaid Services (CMS) Transmittal 442 Date: December 7, 2012

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1 nul ysem ub edice ogm negiy Depmen of elh & umn evices (D) enes fo edice & edicid evices () Tnsmil 442 De: Decembe 7, 2012 hnge eques 8105 UBJT: Upde fo mendmens, oecions nd Delyed nies in edicl Documenion. UY O NG: The pupose of his is o povide insucions o concos egding mended, coeced, nd delyed enies in medicl ecods. TV DT: Jnuy 8, 2013 LNTTON DT: Jnuy 8, 2013 Disclime fo mnul chnges only: The evision de nd nsmil numbe pply only o ed ilicized meil. ny ohe meil ws peviously published nd emins unchnged. oweve, if his evision conins ble of conens, you will eceive he new/evised infomion only, nd no he enie ble of conens.. NG N NUL NTUTON: (N/ if mnul is no upded) =VD, N=NW, D=DLTD-Only One e ow. /N/D T / TON / UBTON / TTL 3/Tble of onens /mendmens, oecions nd Delyed nies in edicl Documenion. UNDNG: o iscl nemediies (s), egionl ome elh nemediies (s) nd/o ies: No ddiionl funding will be povided by ; conco s civiies e o be cied ou wih hei opeing budges. o edice dminisive oncos (s): The edice dminisive conco is heeby dvised h his consiues echnicl diecion s defined in you conc. does no consue his s chnge o he semen of Wok. The conco is no obliged o incu coss in excess of he mouns lloed in you conc unless nd unil specificlly uhoized by he oncing Office. f he conco consides nyhing povided, s descibed bove, o be ouside he cuen scope of wok, he conco shll wihhold pefomnce on he p(s) in quesion nd immediely noify he oncing Office, in wiing o by e-mil, nd eques foml diecions egding coninued pefomnce equiemens. V. TTNT: Business equiemens nul nsucion *Unless ohewise specified, he effecive de is he de of sevice.

2 chmen - Business equiemens ub Tnsmil:442 De: Decembe 7, 2012 hnge eques: 8105 UBJT: Upde fo mendmens, oecions nd Delyed nies in edicl Documenion TV DT: Jnuy 8, 2013 LNTTON DT: Jnuy 8, GNL NOTON. Bckgound: ovides e encouged o ene ll elevn documens nd enies ino he medicl ecod he ime hey e endeing he sevice. Occsionlly, upon eview povide my discove h cein enies, eled o cions h wee cully pefomed he ime of sevice bu no popely documened, need o be mended, coeced, o eneed fe endeing he sevice. B. olicy: ovides e encouged o ene ll elevn documens nd enies ino he medicl ecod he ime hey e endeing he sevice. Occsionlly, upon eview povide my discove h cein enies, eled o cions h wee cully pefomed he ime of sevice bu no popely documened, need o be mended, coeced, o eneed fe endeing he sevice.. BUN QUNT TBL Numbe equiemen esponsibiliy /B D hed- ysem inines V W Ohe s, T, ecovey udios, nd Zs shll conside ll submied enies h comply wih he widely cceped ecodkeeping inciples when mking eview deeminions The s, T, ecovey udios, nd Zs shll NOT conside ny enies h do no comply wih he ecodkeeping pinciples, even if such exclusion would led o clim denil f he s, T o ecovey udios idenify medicl documenion wih poenilly fudulen enies, he eviewes shll efe he cses o he Z nd my conside efeing o he O nd e gency. B X X X X X X s, T, ecovey udios nd Zs X X X X X X s, T, ecovey udios nd Zs X X X X X X s, T, ecovey udios nd Zs

3 . OVD DUTON TBL Numbe equiemen esponsibiliy /B D Ohe None B V. UOTNG NOTON ecion : ecommendions nd suppoing infomion ssocied wih lised equiemens: N/ X-ef equiemen Numbe ecommendions o ohe suppoing infomion: ecion B: ll ohe ecommendions nd suppoing infomion: N/ V. ONTT e-mplemenion onc(s): gey Glove, o ichel ndign, o os-mplemenion onc(s): onc you oncing Office's epesenive (O) o onco nge, s pplicble. V. UNDNG ecion : o iscl nemediies (s), egionl ome elh nemediies (s), nd/o ies: No ddiionl funding will be povided by ; conco s civiies e o be cied ou wih hei opeing budges. ecion B: o edice dminisive oncos (s): The edice dminisive onco is heeby dvised h his consiues echnicl diecion s defined in you conc. do no consue his s chnge o he emen of Wok. The conco is no obliged o incu coss in excess of he mouns lloed in you conc unless nd unil specificlly uhoized by he oncing Office. f he conco consides nyhing povided, s descibed bove, o be ouside he cuen scope of wok, he conco shll wihhold pefomnce on he p(s) in quesion nd immediely noify he oncing Office, in wiing o by e-mil, nd eques foml diecions egding coninued pefomnce equiemens.

4 edice ogm negiy nul hpe 3 - Veifying oenil os nd Tking oecive cions Tnsmils fo hpe 3 Tble of onens (ev.442, ssued: ) mendmens, oecions nd Delyed nies in edicl Documenion

5 mendmens, oecions nd Delyed nies in edicl Documenion (ev. 442, ssued: , ffecive: , mplemenion: ) This secion pplies o s, T, ecovey udios, nd Zs, s indiced.. mendmens, oecions nd Delyed nies in edicl Documenion ovides e encouged o ene ll elevn documens nd enies ino he medicl ecod he ime hey e endeing he sevice. Occsionlly, upon eview povide my discove h cein enies, eled o cions h wee cully pefomed he ime of sevice bu no popely documened, need o be mended, coeced, o eneed fe endeing he sevice. When mking eview deeminions he s, T, ecovey udios, nd Zs shll conside ll submied enies h comply wih he widely cceped ecodkeeping inciples descibed in secion B below. The s, T, ecovey udios, nd Zs shll NOT conside ny enies h do no comply wih he pinciples lised in secion B below, even if such exclusion would led o clim denil. o exmple, hey shll no conside unded o unsigned enies hndwien in he mgin of documen. nsed, hey shll exclude hese enies fom consideion. B. ecodkeeping inciples egdless of whehe documenion submission oigines fom ppe ecod o n eleconic helh ecod, documens submied o s, T, ecovey udios, nd Zs conining mendmens, coecions o ddend mus: 1. lely nd pemnenly idenify ny mendmen, coecion o delyed eny s such, nd 2. lely indice he de nd uho of ny mendmen, coecion o delyed eny, nd 3. No delee bu insed clely idenify ll oiginl conen pe edicl ecods: When coecing ppe medicl ecod, hese pinciples e genelly ccomplished by using single line sike hough so h he oiginl conen is sill edble. uhe, he uho of he leion mus sign nd de he evision. imilly, mendmens o delyed enies o ppe ecods mus be clely signed nd ded upon eny ino he ecod. leconic elh ecods (): edicl ecod keeping wihin n deseves specil consideions; howeve, he pinciples wed bove emin fundmenl nd necessy fo documen submission o s, T, ecovey udios, nd Zs. ecods souced fom eleconic sysems conining mendmens, coecions o delyed enies mus:. Disincly idenify ny mendmen, coecion o delyed eny, nd b. ovide elible mens o clely idenify he oiginl conen, he modified conen, nd he de nd uhoship of ech modificion of he ecod.. f he s, T o ecovey udios idenify medicl documenion wih poenilly fudulen enies, he eviewes shll efe he cses o he Z nd my conside efeing o he O nd e gency.

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