Wiki Documentation time on the day of visit

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leastratton1001

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Physician sees a patient on 4/17 however does not finish all of their documentation on the date of that encounter and adds documentation in 3 days later. Guidelines that that documenting clinical information in the medical record counts towards time on the date of the encounter. Does this mean that if a clinician fails to enter all of their documentation timely ( and goes back into the medical record the next day or a few days later to finish documentation that we can ONLY count the time spent documenting on the day of encounter or we are able to count it towards the visit it belongs to?
 
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Does this mean that if a clinician fails to enter all of their documentation timely ( and goes back into the medical record the next day or a few days later to finish documentation that we can ONLY count the time spent documenting on the day of encounter
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Yes. Under CPT guidelines the provider can only count time on the calendar date of the face-to-face encounter. So anything the provider did after 11:59 pm on 4/17 wouldn't count toward their time. Note however that Medicare has special rules for counting time for prolonged services with same day/admit discharge, nursing facility and home/residence services. Source: https://www.cms.gov/files/document/r11842cp.pdf
 
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jkyles said:
Yes. Under CPT guidelines the provider can only count time on the calendar date of the face-to-face encounter. So anything the provider did after 11:59 pm on 4/17 wouldn't count toward their time. Note however that Medicare has special rules for counting time for prolonged services with same day/admit discharge, nursing facility and home/residence services. Source: https://www.cms.gov/files/document/r11842cp.pdf
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I am new to E/M and just trying to ensure I am on the right path- Upon looking at the link you provided and reading those areas it looks like that if we were to be using the documentation added later towards prolonged service codes for example a home visit we could use documentation 3 days before the visit+date of the visit+ 7 days after the visit but this would only apply towards prolonged service codes being added correct?
 
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