Wiki Coder liability in timely documentation

kayleeevans907

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Does anyone have insight or resources in relation to the liability that falls on a coder when a provider submits documentation weeks/months after a visit occurred to be coded?
Conversation came up that I could potentially start receiving documentation from however long ago a provider decides to look back and I am expected to charge for it. This does not sound right or ok to me, especially because I know CMS has timely documentation requirements, but I can’t find anything specific citing a timeline or specific age that documents can’t be submitted anymore it was brushed off.
Does this leave me open to legal issues? Or does this only fall on the provider and clinic?
 
It depends on when the documentation actually occurred. Did they submit the charges for the visit/encounter late but the documentation was done at the time of the visit? Or, did they not document at all until days/weeks/months later?

Some "light" reading:


3.3.2.5 - Amendments, Corrections and Delayed Entries in Medical Documentation
All services provided to beneficiaries are expected to be documented in the medical record at the time they are rendered...


I would say it falls on the provider as it is their documentation. However, if I was in the position, I would make my opinion or advice known and possibly that I am not comfortable coding/billing/submitting. I think it depends on the documentation and specific instance though. If it meets all the requirements for amendment, correction, delayed entry and the signature requirements it "might" be okay.
 
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