Wiki documentation

[perkins05]

Can anyone tell me where I can find the date deadline for documentation completion for clinic notes. All help is appreciated.


Thanks

 

[jackson7591]

reference

here is a link regarding E/M services guide.

http://www.cms.gov/MLNProducts/downloads/eval_mgmt_serv_guide-ICN006764.pdf

page 4 states "In order to maintain an accurate medical record, services should be documented during the encounter or as soon as practicable after the encounter."

 

[LindaEV]

There is no "official" timeline, but like the above poster wrote, Medicare uses the term "soon". I have heard a medicare rep say they "recommend" it be 48 hours max, but that person also admits it is not an "official" number.

We have an internal policy that it has to be done within 48 hours.

 

[perkins05]

Thanks Ladies… I just have a physician that thinks they can be complete on his own time.