# Billing in Draft Format



## pclaybaugh (Dec 30, 2013)

Please let me know about hospitalist leaving their electronic notes in "DRAFT" format in our electronic system, we use MediTech. 
I claim that we shouldn't be billing these out until the doctor's e-sign. I am getting lots of push back on this. Sometimes these notes are left in draft for over 4 weeks. 

Also I find many signed and the "DICTATION ANOMALIES" are still present. That tells me the doctor just signed and made no corrections.

When Medicare asks for progress notes, I have a problem printing those and sending them when the system still notes them as "DRAFT".

I have called FirstCoast and haven't gotten a conclusive answer.

Please give me some feedback. Thanks so much.


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## mlbaker1974 (Dec 30, 2013)

*billing in draft format*



pclaybaugh said:


> Please let me know about hospitalist leaving their electronic notes in "DRAFT" format in our electronic system, we use MediTech.
> I claim that we shouldn't be billing these out until the doctor's e-sign. I am getting lots of push back on this. Sometimes these notes are left in draft for over 4 weeks.
> 
> Also I find many signed and the "DICTATION ANOMALIES" are still present. That tells me the doctor just signed and made no corrections.
> ...



when I audit cases. if the record is authenticated by the provider either by electronic signature, hand written signature or mark, we would accept it as appropriate documentation and audit accordingly.


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## pclaybaugh (Dec 30, 2013)

Thanks Misty,

What about the dictation anomalies? The words the transcriptionist failed to clarify. Isn't it the doctors responsibility to clear those up prior to signing?.
Also, what do you deem acceptable as far as timely signing?


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## TTcpc (Dec 30, 2013)

Hello,

To give some input on how the practices that I work with handle things...

We give the physicians 72 hours (does not include weekends or time off days) to sign off on their documentation, after 72 hours I send a message to the provider through our EMR so I have a record of whether they have viewed it or not and they are given 48 hours to sign/respond, after this additional time if the note is still not signed off on (out of draft status) the matter is elevated to the office manager and medical director to address.  Depending on whether this is a pattern with the provider depends on the action that they take from there; some have to use their admin time for the week to complete them or in the worst case their schedule is cleared/frozen until it is done (have only heard of this having to happen once!).  This falls pretty close in line with what our hospital requirements are.  I am surprised that your hospital lets them get away with leaving them in draft status.  

In regards to the physician signing off on the note without correcting transcription mistakes, we have instructed/advised our physicians that once they sign off on the note, all responsibility falls on them in the event of an audit or worst case scenario a lawsuit and that their signature serves as acknowledgment that they have reviewed the note for accuracy.  Some notes I have seen have been so bad that I have even sent the message to the provider to remind them of this...some listen and go back and fix the errors and some do not.

I hope this helps.  I know it's not "official" guidance, but might help you get a process started where you are.  I wish you well in this endeavor as I know it can be difficult sometimes to get them to understand


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## pclaybaugh (Jan 6, 2014)

Thanks ever for the comprehensive answer. I will be passing this on and hopefully we can get the policy changed.


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## mlbaker1974 (Jan 7, 2014)

*documentation*



pclaybaugh said:


> Thanks Misty,
> 
> What about the dictation anomalies? The words the transcriptionist failed to clarify. Isn't it the doctors responsibility to clear those up prior to signing?.
> Also, what do you deem acceptable as far as timely signing?



Yes the provider is responsible for correcting the dictation anomalies. However, I do see records that are missing a word or two and as long as I can determine what was done I accept it.  As for timely signing, I am attatching the CMS link.  Hope this helps.

http://www.cms.gov/Outreach-and-Edu...gnature_Requirements_Fact_Sheet_ICN905364.pdf


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