The Medicare Integrity Manual states that on review an auditor can "give less weight" to any entries over 30 days past the date of service. If they find habitual offenders of this they can report them to ZPIC.
LeeAnn
Information added (or taken away), and/or late entries to a medical record should be "timely". It needs to be signed and dated with current date (vs date of service). These additions or late entries are done for clarification of a medical record. It cannot be done for billing purposes. You bill based on what is in the record at the time the claim goes out. Anything added to support billing codes (like when records re requested for pre or post payment review) is not legal.
Since you are not the physician you cannot tell him what to document regarding what he did or discussed with a patient while you are not present. However I never submit a claim without a complete review of the encounter note, if the code selected by the provider is not supported by the note then I do alert them to this and let them know that if the document is amended within 24 hours the claim will reflect the level of care supported by the note.I have a situation in which I was requested to do a coding reveiw (after claim processing). I found the documentation to be lacking and downcoded several E/M and disallowed procedures due to poor or no documentation to support the application of the CPT code. Now the physician wants we to send back current charts noting "what needs to be added" to gain the higher level (i.e. add elements to exam or ROS or HPI etc). I am totally and completely opposed to this but i NEED specific authoritative reference to support my position - this has become contentious.