Wiki note date not reflecting billed service date

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vcar

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I bill on the physician side. I have a couple of "old school" providers who make notes with paper and pen during the visit. Then at a later date they document the visit in the EMR. Sometime the note is entered weeks later. The issue is the EMR enters the date the note is entered as the note (service) date, not the actual date the patient was seen. Example - patient seen on 8/10 provider enters documentation in the EMR on 8/30. The EMR documentation shows "note date : 8/30/20. I would understand the EMR reflecting the date note was entered if the provider would then go on to state something like late entry patient seen on ___________. Which is how it was handled with paper charts. Provider doesn't see the need to "correct" the note date or add anything additional to reflect the actual service date. I've explained that if the carrier requested the note to justify a claim the service date on the claim and the note date wouldn't match. I see this as an issue but am being overruled. There's no compliance department but I have taken this to my supervisor. Am I way off base???
Thanks
 
I think you have a valid concern, but at the same time, I believe this is a fairly common issue with EHRs, one which I've seen in practices in the past. I suspect that payers are aware that this can be an issue, and if you ran into a problem with a payer audit, you could probably explain your way out of it by showing the auditor the practice's scheduling system to support that the dates that were billed do match the dates that the patient was actually seen at the practice even if that doesn't appear on the printed version of the note itself.

But you're right in that it could potentially cause a headache in an audit, so although I'd recommend not being overly alarmed about this, I would still gently keep trying to push the providers to find a way to make sure their notes accurately reflect the dates. You may want to consider working with your software vendor to get a fix into the provider's templates which might automatically pull the visit date into the notes from the scheduling system without the providers having to manually enter it. We were able to do this with a system that the practice used where I worked a number of years ago and where we were having this very same problem.
 
Since carriers are all about not paying claims and/or recouping their money I'll suggest reaching out to the software vendor. Less time we have to devote to fighting for payment the better. Thanks Thomas.
 
When the patient checks in, does that start the visit note? If so, then the provider would just edit the visit note later to add his portion. Or, the Medical Assistant could start the visit note by entering the vitals, and then the provider adds his part at a later date. Our software has an option to allow editing a visit note, not allow, allow with a password, etc.
 
I don't think the note starts at check-in. Will have to double check. The MA writes vitals down on paper for provider. The provider enters that documentation into the EMR. The provider can edit when they are entering their documentation they just don't/won't.
Thanks.
 
Then I would suggest the MA start the visit note with the chief complaint and vitals. At least that would get the correct date, and the provider can add on at his leisure.
 
MA is doing as the provider wants. Like I said, providers are "old school". Will just keep trying to persuade them. Thanks Sharon.
 
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