How soon after a visit must the documentation be complete?

July 27th, 2015 - Codapedia Editor

Categories: Compliance

Most physicians, Nurse Practitioners and Physician Assistants document the service they have performed on the same calendar date. Occasionally, at the end of the day, the service might not be documented before the clinician leaves the office, particularly if called away urgently. In that case, the service is documented the next day. But, how soon after the service is performed does Medicare require it to be documented?

Medicare does not set a specific time period. Here's what the Medicare Claims Processing Manual says in Publication 100-04, Chapter 12, Section 30.6.1 A:

The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record.

Given this statement, what policies should a group have? Many groups require that all documentation is completed no later than 48-72 hours after the service is provided, and encourage all documentation to be completed on the same day as the service is performed.

Some groups, which are owned by hospital systems, may be subject to JCAHO policies. For services provided in the hospital, the hospital mandates that medical records are completed within certain time frames, in order to meet JCAHO or Conditions of Participation rules.

Groups know which providers have trouble completing their records in a few ways. For those using paper records, charts may remain stacked in a provider audit for days or weeks on end. Then, someone needs that record, the chart is removed and the service may or may not ever be documented. Missing dictations which occur with any frequency are a warning signal. Walking by a provider office can tell you accurately that the provider is behind on documentation--it's usually no surprise to anyone. If the office is using electronic medical records, the practice manager can run a report daily to show which services are not completed. Whatever method is used, the practice must address physicians who do not complete documentation as a compliance issue.

If the services are not documented, the practice may not bill for them. Some times, physicians who know they won't get credit for the work will get up to date. If the services are not documented in a timely manner, the Compliance Committee or Governing Board must provide increasing sanctions for the physician. Failure to do so is both a clinical and a compliance issue.

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