Wiki Provider documentation timeline

[coder1]

Good Afternoon Coding World,


Do anyone know where I could found creditable source for provider documentation guidelines. I work for an employer that's under the impression they could wait for a month to document visits.

 

[nsteinhauser]

Per the CMS 'Claims Processing Manual,' Chapter 12 - Physicians/Nonphysician Practitioners, Section 30.6.1:
http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf

"Documentation should support the level of service reported. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record. "

If CMS fails to motivate, attorneys specializing in medical/malpractice cases may be able to effectively communicate to the provider the potential professional and monetary consequences of not documenting promptly.

Hope this helps.

 

[coder1]

Thank you