Medical Record Entries: What Is Timely and Reasonable?
Because so many factors weigh into the answer, it depends.
By Robert A. Pelaia, Esq., CPC, CPCO
Every year at AAPC’s 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, audience members have asked for guidance on medical record entry timeliness and reasonable record keeping. This is not an easy topic and there is no one answer that will apply to the many scenarios coders encounter.
In 2006, however, useful and practical guidance regarding medical record documentation was released by the medical director of First Coast Service Options, Inc. (FCSO). The current Medicare administrative contractor for Puerto Rico, the U.S. Virgin Islands, and Florida also has recently issued helpful information regarding this. In addition to several other issues, FCSO’s medical director touched upon the overall timeliness of documentation, medical record addenda, legibility, and “cloning.” Here are selected excerpts in regards to timeliness from the FCSO memo (see pages 3-6), followed by practical compliance tips that apply to each issue raised.
Medicare Comment No. 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: Medicare has clearly stated that “reasonable” means 24 to 48 hours. 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’s unreasonable to expect a provider to recall the specifics of a service two weeks after the service was rendered. Nor should an entry be made in advance.
Medicare Comment No. 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: 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 (An addendum should not be added to the medical record without identifying it as such.)
- The date of the service being amended
- The signature of the provider writing the addendum
The medical record should be amended within a reasonable time that would allow the service provider to recall the specific details of the patient encounter. Medical record addenda 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 No. 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: Again, 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’s also important to remember that medical record addenda need to be made to the original medical record, not just to the billing copy.
Medicare Comment No. 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: Legibility of medical record documentation is not just a billing issue; it’s 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. Notes should be timed and dated appropriately, as well. The timing of a medical record note is especially important in inpatient charts, emergency department settings, trauma settings, and critical care units. It’s especially critical for the service provider’s identity to be legible. Signatures also should include the provider’s credentials.
Medicare Comment No. 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: Templates certainly are useful tools, but providers must use caution when applying “templated” language. Specifically, (although it may seem obvious) providers must ensure that what is being represented in the medical record actually took place and isn’t something the provider normally does, but may not have done for that particular patient.
Robert A. Pelaia, Esq., CPC, CPCO, is senior university counsel for health affairs at the University of Florida College of Medicine in Jacksonville, Fla. He is certified as a Health Care Law Specialist by the Florida Bar Board of Legal Specialization and Education, serves on AAPC’s Legal Advisory Board, and was a 2011-2013 AAPC National Advisory Board member. Pelaia is a member of the Jacksonville River City, Fla., local chapter.