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is there a time constraint on completing documentation

Carolyn Posted Fri 07th of December, 2012 17:34:06 PM

Does a provider have to complete there documentation within a certain period of time before it is no longer billable? (ie 24 to 48 hrs after seeing the patient?)

SuperCoder Answered Fri 07th of December, 2012 22:57:32 PM

Here is what CMS says in the Claims Processing: (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.

That's it. CMS does not give a time limit of hours or days. There are hospital rules about documenting the physician component of medical records, and Health Information departments keep track of those and remind physicians who fall behind.

What policies are reasonable in a phyisician office, and how should those be enforced? Many groups develop a policy that all documentation must be completed within three days. A week at the longest.

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