Question Documentation not completed for up to 6 months

mberthume

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I work in a critical access hospital as an inpatient coder and also as a documentation improvement specialist. One of our admitting providers has a very bad habit of not completing his H&Ps or Discharge Summaries in a timely manner; it is not uncommon for him to complete his documentation MONTHS after the patient has left. Obviously this leads to inaccuracies/inconsistencies in his documentation as well as billing delays.

Is this normal? Is this allowed at other hospitals? The administration at my hospital is giving the impression that this is no big deal, and there are no consequences for this provider. I am at a loss because I can't figure out how I'm supposed to improve documentation that doesn't exist, much less code these inpatient charts. I would like to present some information at my next Quality Meeting showing that this is not an acceptable practice (because it's not, right?) but I can't find a good answer from CMS. Any help that ya'll can give me with this would be so appreciated.
 

Orthocoderpgu

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There is always "one of those" at every hospital/clinic it seems. No it is not normal. To be honest, documentation that has been completed and authenticated months later is basically worthless. The physician has seen too many patients in between to document anything with specificity. And if this provider ever found himself in court their defense would be "well, any mistakes or inaccuracies would be due to the elongated time in which my documentation was completed". Or something along those lines. You can't code what it not there and administration does not seem to care. Most insurance companies require billing within 90 days from the date of service. I would imagine the money that is being lost. Maybe keep a running tab of how much money is potentially lost. I've worked with providers like this before and they usually end up going down the road since their delayed decisions effect many others they work with. You can get further assistance from your MAC for specific guidelines, but a small delay of a few days is not abnormal, but past that your increasing your chances of legal action. Thomas?
 

SharonCollachi

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I read reports from the Medical Board of California on a regular basis, to see what sorts of things they are looking for.

Whenever there is an issue with a physician working in a hospital, it seems there is ALWAYS an issue with late documentation, and they cast a lot of doubt on the doctor's recollection of events. Check with your state licensing body and see if there is a code of ethics, or on the AMA website, or his specialty association.
 

csperoni

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To my knowledge, CMS does not precisely define a time period, but states something like as soon as practical. Some MACs give a more exact definition of when documentation must be completed and signed. Certainly, months later is not timely. I do not work directly for a hospital, but my physicians operate out of several hospitals. Most of them will send a delinquency notice at 7 days, and then call about a week after if still not complete. Once it reaches a certain point (usually 20-30 days), they threaten to suspend the providers privileges and call again. After another 7-10 days, they will actually suspend the provider. They can't use their badge to get into the hospital, can't log onto systems, etc.

According to this AAPC article, documentation should be completed and signed within 24-48 hours. However, I have never heard of Medicare (or any carrier) denying a claim if the signature is 4 days later.
 

thomas7331

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I work in a critical access hospital as an inpatient coder and also as a documentation improvement specialist. One of our admitting providers has a very bad habit of not completing his H&Ps or Discharge Summaries in a timely manner; it is not uncommon for him to complete his documentation MONTHS after the patient has left. Obviously this leads to inaccuracies/inconsistencies in his documentation as well as billing delays.

Is this normal? Is this allowed at other hospitals? The administration at my hospital is giving the impression that this is no big deal, and there are no consequences for this provider. I am at a loss because I can't figure out how I'm supposed to improve documentation that doesn't exist, much less code these inpatient charts. I would like to present some information at my next Quality Meeting showing that this is not an acceptable practice (because it's not, right?) but I can't find a good answer from CMS. Any help that ya'll can give me with this would be so appreciated.
Thinking that a six month delay in billing their claims is 'no big deal' would be fiduciary irresponsibility, but it's possible that they have no choice. I agree with the responses above, and most organizations don't tolerate this due to the potential financial impact it has. However, I think some small hospitals in remote areas that have difficulty recruiting physicians to staff their services perhaps do not enforce this very strictly simply because they fear alienating providers and cannot afford to suspend or lose their physicians. In that sense, they can be 'stuck between a rock and a hard place'. That could be the case with your hospital. The financial impact of not having enough physicians to be able to provide care for their patients could be greater than the loss of revenue or potential risk involved in documentation delays.
 

mberthume

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Thinking that a six month delay in billing their claims is 'no big deal' would be fiduciary irresponsibility, but it's possible that they have no choice. I agree with the responses above, and most organizations don't tolerate this due to the potential financial impact it has. However, I think some small hospitals in remote areas that have difficulty recruiting physicians to staff their services perhaps do not enforce this very strictly simply because they fear alienating providers and cannot afford to suspend or lose their physicians. In that sense, they can be 'stuck between a rock and a hard place'. That could be the case with your hospital. The financial impact of not having enough physicians to be able to provide care for their patients could be greater than the loss of revenue or potential risk involved in documentation delays.
Thomas, I think you hit the nail on the head. This doc is our biggest admitter, and I know there is a fear of losing him and the patients he brings in. At the same time, what good is he doing our patients or our hospital when there is essentially no continuity of care and so much revenue is lost due to timely filing? We track his delinquent records and email him every Friday with an update. Last week he caught up on his charts, totaling over $200,000 of billed charges. Some of these charts were from back in May and his documentation made no sense; ethically I wasn't sure what I could even code. At this point I've decided that I will voice my concerns to our administrative staff, present them with whatever information I can find, and then follow their lead with whatever decision they make. It just kills me to keep letting this slide because I am passionate about my job and the part that documentation plays in quality healthcare.
 
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