Wiki Date of Service - I am wondering


Albertville, MN
Best answers
I am wondering where in writing that it states the date of service is the actual face-to-face time with patient? The physicians I code for say that the dictation time is in real-time and that is the date of service. The dictation software people say so. SO, I know that dictation time is not the face-to-face time with patient. I NEED in writing somewhere the definition. I have looked extensively at the CMS and WPS websites, and I can find nothing. It seems to inferred. The physicians will only believe what is in writing.
I appreciate any help, Thanx!
Annette, CPC, CEMC
Are your doctors trying to bill a different date because they dictated the note the next day or something? I have never heard of such a thing!!

If you google Date of Service definition this is what you will find.

Definition of Date of Service:

The date the insured was seen by a health care practitioner or given medical treatment.

The date of service is the face-to-face encounter and what the insurance is paying for - they are not paying for the dictation. If there is no face-to-face encounter, than there is no visit. The dictation is documenting what was done during that encounter and is to be completed immediately, not at another time. When the doctors dictate their notes may be real to them, but the real time when they saw the patient is the date of service!!

Instead of trying to find the definition of date of service from CMS maybe try to locate a policy on when a note is supposed to be documented by - such as OR notes need to be documented immediately! Or have your doctors provide you documentation to support their point of view - I'm sure they won't find anything!!

Hope this helps!