Neurology & Pain Management Coding Alert

Question: We are having an issue with providers sending us unsigned medical records for billing. We have communicated with the providers on a number of occasions that they need to sign the patient note before sending for billing. I have looked online to see if there is any guidance from the Centers for Medicare & Medicaid Services (CMS) on what is considered an acceptable time frame for signing medical records and there doesn’t seem to be one. So, what is regarded as reasonable or acceptable?

AAPC Forum Participant

Answer: You are right in saying Medicare doesn’t provide specific guidelines for what constitutes a timely sign-off on a medical record. The closest Medicare gets to defining a time frame is in Section 30.6.1(A) of Chapter 12 of the Medicare Claims Processing Manual, which states, in part, that “the service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record” (www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/ Downloads/clm104c12.pdf).

Some Medicare Administrative Contractors (MACs) have offered more concrete guidance, however. Medical directors for Wisconsin Physicians Service Government Health Administrators (WPS GHA), the MAC for jurisdictions 5 (Iowa, Kansas, Missouri, and Nebraska) and 8 (Indiana and Michigan), for example, have gone on record as saying that “practitioners are expected to complete the documentation of services at the time they are rendered.” They acknowledge that the Medicare Claims Processing Manual “does not provide any specific period to reflect as soon as practicable,” and so they “offer a reasonable time frame of 24-48 hrs” (https://www. wpsgha.com/wps/portal/mac/site/claims/guides-and-resources/ completion-of-documentation/).

In the end, WPS GHA offers this sage advice regarding signing off on the medical record in a timely manner: “Accurate and timely completion of medical records is part of the provider’s responsibility to the patient and Medicare. Ask yourself, ‘How can I remember seeing all my patients and what happened during that visit if more than 24-48 hours has passed?’”