Medical Record Entry Timeliness: What Is Reasonable?
By Robert A. Pelaia, Esq., CPC
Every year at the AAPC national conference, several members of AAPC’s Legal Advisory Board present an open forum session to respond to a wide variety of questions from attendees. For the past few years, without fail, numerous audience members have asked for guidance on the timeliness of entries to the medical record. This is not an easy topic and there is no way to give one answer that will apply to the many scenarios that coders may encounter.
The medical director of First Coast Service Options, Inc. (FCSO), the Medicare Part B carrier for Florida and Connecticut, recently issued some useful and practical guidance regarding medical record documentation. In addition to several other issues, the medical director touched upon the overall timeliness of documentation, medical record addenda, the legibility of medical records and medical record “cloning.”
The following are some selected excerpts from the memo, followed by some practical compliance tips that apply to each issue raised.
Medicare Comment #1: Medicare expects the documentation to be generated at the time of service or shortly thereafter. Delayed entries within a reasonable time frame (24 to 48 hours) are acceptable for purposes of clarification, error correction, the addition of information not initially available, and if certain unusual circumstances prevented the generation of the note at the time of service.
Compliance Tips on Comment #1: Medicare has clearly stated that “reasonable” means 24 to 48 hours. As such, it is important to understand that anything beyond 48 hours could be considered unreasonable. Providers should comply with this requirement and complete documentation in a timely manner. Those responsible for coding and/or entering charges need to be cognizant of the timeliness of medical record completion. It is not reasonable to expect that a provider would normally recall the specifics of a service two weeks after the service was rendered. An entry should never be made in advance.
Medicare Comment #2: The medical record cannot be altered. Errors must be legibly corrected so that the reviewer can draw an inference as to their origin. These corrections or additions must be dated, preferably timed, and legibly signed or initialed.
Compliance Tips on Comment #2: To properly execute a medical record addendum, the provider must, at a minimum, write the following details in the medical record:
- The date the record is being amended.
- The details of the amended information.
- A statement that the entry is an addendum to the medical record (it is not appropriate to add an addendum to the medical record without identifying it as such).
- The date of service of the service being amended.
- The signature of the provider writing the addendum.
The medical record should be amended within a reasonable period of time that would allow the provider of service to recall the specific details of the patient encounter. Medical record addendums should be an exception rather than a routine or recurring part of medical record documentation. Medical record addenda must be properly identified and reference must be made to the original note being amended. Failure to properly amend the medical record may give the appearance of “falsifying documentation,” which is considered fraudulent.
Medicare Comment #3: Every note must stand alone, i.e., the performed services must be documented at the outset. Delayed written explanations will be considered. They serve for clarification only and cannot be used to add and authenticate services billed and not documented at the time of service or to retrospectively substantiate medical necessity. For that, the medical record must stand on its own with the original entry corroborating that the service was rendered and was medically necessary.
Compliance Tips on Comment #3: Addenda to the medical record should not be a normal practice — these should be the exception and not the rule. Coders responsible for reviewing documentation should be cognizant of providers who demonstrate patterns of insufficient documentation that necessitate addenda. It is important to remember that medical record addenda need to be made to the original medical record, not just to the billing copy.
Medicare Comment#4: All entries must be legible to another reader to a degree that a meaningful review may be conducted. All notes should be dated, preferably timed, and signed by the author.
Compliance Tips on Comment #4: Legibility of medical record documentation is not just a billing issue; it is a patient care issue. Illegible documentation may result in medication errors and incorrect diagnoses being assigned to the patient. The medical record must be legible to an individual who is not familiar with the provider’s handwriting. In addition, notes should be timed and dated appropriately. The timing of a medical record note is especially important in an inpatient chart, emergency department settings, trauma settings, and critical care units. It is especially critical that the identity of the provider of service be legible. Signatures should also include the provider’s credentials.
Medicare Comment #5: Documentation is considered cloned when each entry in the medical record for a patient is worded exactly alike or similar to the previous entries. Cloning also occurs when medical documentation is exactly the same from patient to patient. It would not be expected that every patient had the exact same problem, symptoms, and required the exact same treatment. Cloned documentation does not meet medical necessity requirements for coverage of services rendered due to the lack of specific, individual information. All documentation in the medical record must be specific to the patient and her/his situation at the time of the encounter. Cloning of documentation is considered a misrepresentation of the medical necessity requirement for coverage of services. Identification of this type of documentation will lead to denial of services for lack of medical necessity and recoupment of all overpayments made.
Compliance Tips on Comment #5: Templates certainly are useful tools, but providers must use caution when applying “templated” language. Specifically, it may seem obvious, but providers must ensure that what is being represented in the medical record actually took place and is not something that the provider normally does but may not have done for that particular patient.