Wiki Late Entries

[s_harris14]

Hello!

I have a provider who is consistent on dictating both office E/M and initial hospital encounters late, sometimes months after the service is performed and sometimes not at all. I can't find any specific guidelines that provide a cutoff for dictating and billing E/M services. From the billing standpoint, it can be billed as long as it is within the insurance payer's time filing limits. However, I want to establish and enforce a policy within our office that promotes timely dictations, not only for the purpose of expedited billing and reimbursement, but also so that the patient's PCP/referring/other treating physicians are receiving a summary of our care and recommendations in an appropriate time frame. This is frustrating for me because the provider takes the time to perform the service, but not the additional time to document...and as we all know if it's not documented, it didn't happen. I don't want to miss opportunities to bill for E/M services.

What is your office policy for late entries? Do you require your physicians to dictate their E/M services within a specific time frame? Would you bill for an E/M service that is performed months after the service is performed, to include initial hospital encounters that are billed after the patient is discharged from the hospital??

Thank you for your time and input.

 

[Dialmam]

Our organization has written policies that address this... all inpatient to be finalized within 24 hrs and outpatient within 48 hrs. HOWEVER, we have a few MDs that completely ignore this policy and it is a HUGE issue for us, as we will not bill an incomplete note.

Unfortuantely, there is no consequence when physician's don't do this part of their job. I know if I consistently didn't do an important piece of my job, i would be fired. Unfortunately, MDs are considered to be on a pedestal....

 

[cheermom68]

documentation

Medicare says that documentation should be completed within a few days of the encounter. They have also said that documentation should not go beyond 30 days. Their auditors do not have to accept documentation that is 30 days post encounter. They also state that late signatures should never be applied.

If you are attesting to Meaningful use, it will be impossible to be successful if the provider is a late documentor because the patient must be able to obtain an electronic visit summary within 72 hours, if the documentation is not complete, this cannot be accomplished and MU is not successful.

LeeAnn

 

[jdibble]

Medicare says that documentation should be completed within a few days of the encounter. They have also said that documentation should not go beyond 30 days. Their auditors do not have to accept documentation that is 30 days post encounter. They also state that late signatures should never be applied.

If you are attesting to Meaningful use, it will be impossible to be successful if the provider is a late documentor because the patient must be able to obtain an electronic visit summary within 72 hours, if the documentation is not complete, this cannot be accomplished and MU is not successful.

LeeAnn

LeeAnn - do you have the link to this information from Medicare? I have the same issue with one of my doctors - she sometimes goes 2 months without documenting her office notes! Hospital visits aren't as much as a problem because they can impose a suspension if her documentation is not timely, but for the office, we have thrown our hands up in the air! If I can get an official document on what Medicare states is timely, then I can work on getting a policy in place!!

Thanks,

 

[s_harris14]

Thank you all for your responses. I feel a little better knowing that I am not alone with this struggle!

I agree that setting an official practice policy requiring documentation to be completed & signed within a few days is ideal for compliance as well as revenue.

I couldn't find the information on the Novitas website in regards to a specific Medicare policy, but I did find this from WPS:

http://www.wpsmedicare.com/j8macpartb/claims/submission/documentation-timelines.shtml

Thanks again!
Stephanie