Don’t Let Untimely Documentation Hurt Your Practice
Timely, thorough medical record charting guards against lawsuits and revenue loss.
What is the appropriate time frame for completing medical record documentation in the office setting?
According to Medicare, “The service should be documented during, or as soon as practicable after it is provided, in order to maintain an accurate medical record.” Providers should comply with this guideline and complete documentation in a timely manner.
What is “as soon as practicable?” The Centers for Medicare & Medicaid Services (CMS) does not say. But some Medicare fiscal intermediaries (FIs) believe it unreasonable for a provider to recall the specifics of service beyond “a reasonable time frame” of 24 to 48 hours.
With this expectation from FIs, those responsible for coding and/or entering and submitting charges need to be cognizant of the timeliness of medical record completion.
If you are not a Medicare provider, you may think that you do not need to adhere to these documentation requirements. However, other payers and organizations tend to follow Medicare requirements and recommendations. Medical record “charting” seems simple, especially now with most providers using electronic health records, but the process has many pitfalls.
A Case (or Two) for Timely Documentation
A significant dual challenge is charting in a timely manner while caring for the patient. Many cases show, however, that careful and simultaneous medical charting is the best way to prevail when a dispute arises over patient interactions.
Example 1: Failure to Document
One reported example of failing to comply with timely documentation of a patient encounter involves a physician who received an after-hours call from a patient complaining of a severe headache. The physician instructed the patient to go to the emergency room (ER) for an evaluation. The patient responded, “Okay,” but never went to the ER as instructed and had a massive cerebrovascular accident later that night. The patient subsequently sued the physician, alleging that the physician did not direct her to go to the ER. Her allegations were backed by a friend’s witness testimony. Unfortunately, the physician did not document the content of the phone call or her instructions to the patient. If the physician had simply documented the conversation, the physician may have avoided a lawsuit.
Example 2: Successful Documentation
Contrast the previous case with another case involving a physician who determined that a patient needed a test performed as soon as possible. During an office visit, the physician informed the patient of the importance and urgent need for her to receive a specific test. The physician documented this discussion in the medical decision-making section of the note. The patient agreed and the physician personally called the testing facility to schedule the appointment while the patient was in the office.
The physician expected the test results in two days and kept the patient’s medical record on his desk as a reminder to follow up. When the results did not arrive as expected, the physician called the testing facility and was informed that the patient did not show up for the scheduled test. The physician promptly called the patient’s home and was informed that the patient was on vacation in Europe. The physician left a message for the patient to call the office upon her return. This follow-up and phone call was documented on the day of the call in the patient’s chart.
During the patient’s trip, she became extremely ill. The patient subsequently attempted to sue the physician for failing to tell her the importance of completing the test in a timely manner. However, due to the physician’s detailed documentation efforts of these events, a lawsuit was avoided.
Billing and Reimbursement Impact
Proper and timely documentation not only protects physicians and practices from legal issues; it protects reimbursement, as well.
Per WPS Medicare:
A provider may not submit a claim to Medicare until the documentation is completed. Medicare states if the service was not documented, then it was not done. This means that if your physician or non-physician practitioner (NPP) is one that delays documenting the service he/she provided and chooses a date once a month, or once a quarter to complete documentation, then the claim CANNOT be submitted to Medicare until the documentation is complete. You do not have to wait on the practitioner’s signature, under many MAC directions, but the entry into the medical record must be complete prior to submission for payment.
In circumstances where documentation is unable to be completed, a note should be added to the record to explain the delay. The guidance includes a few obvious examples of acceptable and unacceptable excuses.
Note: These Medicare guidelines are for general medical office practice settings. For hospital documentation requirements, please contact your hospital compliance department.
Best Practice
Timely documentation helps to provide the physician and others with a more accurate and informed timeline of patient services and encounters. More importantly, it can help the provider mitigate the risk of malpractice allegations. Completing and signing off on charts within 24 to 48 hours is a good compliance risk strategy to avoid unfinished charts slipping through the cracks.