Cardiology Coding Alert

Question: How do I know if a medical record is completed in a “timely” manner? Can I submit a claim before the encounter is complete?

Nebraska Subscriber

Answer: According to the Centers for Medicare & Medicaid Services (CMS), which set the standards by which many commercial carriers also operate, “timely manner” isn’t strictly defined. Various Medicare Administrative Contractors (MACs) offer these suggestions:

Palmetto GBA: “Medicare providers must comply with documentation requirements, including the timeliness of documentation in connection with the provider signature. Unless the documentation for a service is completed; including signature; a provider cannot submit the service to Medicare,” the Part B MAC says. Medicare states if the service was not documented, then it was not done.

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.”

Noridian: “After a service has been rendered, what amount of time is acceptable to Medicare for the doctor to sign the notes? In most cases, Noridian expects that the notes are signed at the time services are rendered. Further delays may require an explanation,” the Medicare carrier explains.

First Coast Service Options (FCSO): “Medicare expects the documentation to be generated at the time of service or shortly thereafter. Delayed entries within a reasonable time frame (24 to 48 hours) are acceptable for purposes of clarification, error correction, the addition of information not initially available, and if certain unusual circumstances prevented the generation of the note at the time of service,” according to FCSO guidance.