Wiki Creating a note from memory🤔

Sarah Ann

Concord, NH
Best answers
Let's just say our policy is to follow CMS guidelines. I have some reports that are not finalized (the encounter documentation is absent) we're talking like more than a month.
I'm hoping they(providers) keep written notes, but honestly I really don't think they do (IMHO). I had a provider document in the report "created from memory"- Can this still be used as a face to face encounter, for submitting codes for E/M and HCC's?
Just my thoughts here: as coders, our job is to report what providers document, not to decide if they’re doing their jobs correctly, and certainly not to try to judge how good their memory is about the work they did. As there’s no rule anywhere that says this comment in the note would disqualify the documentation, I would go ahead and code is as you would any other encounter. It might be worth mentioning to the provider if you do a documentation quality review session that comments like this in a record and delays in documenting could potentially cause an auditor to lose confidence in the accuracy of the information, but beyond that I don’t think there’s much to be done. Providers are the ones who are ultimately responsible for the integrity of their own work.
I coded it, I was just wondering if it met the the face to face on the DOS requirement. I wasn't questioning the provider.
I guess I misunderstood your question. The documentation should reflect whether or not the provider actually saw the patient in person. Or if there was any question, the appointment records would show if the patient was in the office on that day. I interpreted "created from memory" to mean that the provider wrote the notes based on their recollection of the encounter.