Ask the Expert

This month’s selection:

We have been following Medicare guidance concerning the expectation that documentation is completed and signed off on within 24 to 48 hours from the date of service. But the question has been posed if there is a reference to cite with a definite time range to educate providers on this matter.

I have searched the Medicare website but can find nothing that cites that specific verbiage. Is there a reference you can offer that can help explain timely documentation practices to our providers?

Rachel Adkins, CPC, CPMA, COBGC, COPC
Medical Coding Auditor
Valley Health Systems, Inc, Huntington, West Virginia

Response:

Palmetto GBA says, “Providers are expected to complete the documentation of services ‘during or as soon as practicable after it is provided in order to maintain an accurate medical record.’ This statement is from the Centers for Medicare & Medicare Services (CMS) Internet-Only Manual (IOM) Publication 100-04, Chapter 12, Section 30.6.1. CMS does not provide any specific period, but a reasonable expectation would be no more than a couple of days away from the service itself.”

AAPC and RACmonitor say that, according to Medicare, “The service should be documented during, or as soon as practicable after it is provided, in order to maintain an accurate medical record.” So, what is considered “as soon as practicable” or “timely and reasonable?” Although CMS does not provide any specific period to reflect “as soon as practicable,” some Medicare fiscal intermediaries have defined a reasonable time frame as 24 to 48 hours.

AAPC adds, “Timely documentation helps to provide the physician and others with a more accurate and informed timeline of patient services and encounters. More importantly, it can help the provider mitigate the risk of malpractice allegations. Completing and signing off on charts within 24 to 48 hours is a good compliance risk strategy to avoid unfinished charts slipping through the cracks.”

— Leigh Poland, RHIA, CCS, CDIP, is vice president of coding service line at AGS Health.