Attestations and Addendums

For years I have advocated the use of attestations and addendums when supplementing documentation responses to Medicare audits. In fact, I still have the Administrative Law Judge’s (ALJ) favorable opinion I received in 2009, in which the ALJ wrote that it was the first time he had seen medical documentation supplemented by a physician’s attestation in response to a ZPIC’s request for additional records. Since 2009 the use of attestations and addendums has become more common as a method of supplementing a deficiency or mistake in medical records. Still, many criticize the use of attestations and addendums because Medicare (and consequently, ALJs) does not “like” or “approve” of their use. The purpose of this column is to discuss the relevance and use of attestations and addendums in Medicare audits.

Critics cite Chapter 5, Section 5.7 of the Medicare Program Integrity Manual (MPIM) (Pub. 100-08) as evidence of Medicare’s disapproval of the use of attestations and addendums. Specifically, Section 5.7 specifies that, for DME to be covered by Medicare, “[T]he patient’s medical record must contain sufficient documentation of the patient’s medical condition to substantiate the necessity for the type and quantity of items ordered. However, neither a physician’s order nor a CMN or a DIF nor a supplier-prepared statement nor a physician attestation by itself provides sufficient documentation of medical necessity, even though it is signed by the treating physician or supplier.” Although the last sentence appears to deny the use of attestations and addendums, it actually merely limits the use of attestations and addendums to situations where the use of one “by itself” would provide sufficient documentation of medical necessity. This distinction, while minute, is critical to the establishing the beneficial use of attestations and addendums.

Section 5.7 of the MPIM makes clear that attestations and addendums can be used to supplement or correct problems with a medical record, but cannot be used if they establish medical necessity on their own. For example, if an HME supplier provides a manual wheelchair (K0001) to a Medicare beneficiary, but the patient’s medical records do not indicate how or why a cane or walker would not satisfy the patient’s mobility-related needs (which is a required element that must be addressed in the progress notes according to all LCDs for manual wheelchairs), as long as the physician determined that a cane or walker would not satisfy the patient’s mobility-related needs at the time of the patient’s visit but simply failed to include that piece of information in the patient’s chart, an attestation or addendum may be used. Given that there are numerous elements required that must be documented to establish medical necessity for a manual wheelchair, as long as the patient’s medical record contains evidence supporting the overwhelming majority of these requirements, an attestation or addendum will not “by itself” be the only record used to establish medical necessity.

Additionally, critics point to the fact that the Medicare manuals do not address attestations or addendums. However, on Jan. 8, 2013, CMS implemented Section 3.3.2.5 of Chapter 5 of the MPIM, entitled “Amendments, Corrections and Delayed Entries in Medical Documentation.” Section 3.3.2.5 states: “Occasionally, upon review, a provider may discover that certain entries, related to actions that were actually performed at the time of service but not properly documented, need to be amended, corrected, or entered after rendering the services. When making review determinations the MACs, CERT, Recovery Auditors, and ZPICs shall consider all submitted entries that comply with the widely accepted Recordkeeping Principles.”

According to the Recordkeeping Principles, amendments, corrections or addenda must:

• Clearly and permanently identify any amendment, correction or delayed entry as such
• Clearly indicate the date and author of any amendment, correction or delayed entry, and
• Not delete but instead clearly identify all original content

As you can see, the case for the use of attestations and addendums is strong it also has legal support, as long as Medicare’s rules are followed carefully. Hopefully this argument can now be put to rest … at least until Medicare changes the rules again.