Wiki E/M Billing - time

JRae5M

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Byron Center, MI
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I have been seeing more notes where Clinicians are choosing E/M levels based on
time, but the note has an electronic signature for 2 days or so after the DOS. This
makes me nervous that an outside auditor would question the time vs work on the DOS.
Is there an official guideline that I could give the Clinicians on this? Or how has anyone
else handled this? Would adding a clarifying statement be enough?
 
I think a signature within 24-72 hours would be a normal thing. I think adding some sort of statement or something would proably make it worse. It's always best if the signature date matches the service date but it's not always realistic. See below. No one really defines short delay but generally 24-72 hours is reasonable.

"The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record."
"What should I do if I didn’t sign an order or medical record? You can’t add late signatures to orders or medical records (beyond the short delay that happens during the transcription process). We don’t accept retroactive orders."
 
I have been seeing more notes where Clinicians are choosing E/M levels based on
time, but the note has an electronic signature for 2 days or so after the DOS. This
makes me nervous that an outside auditor would question the time vs work on the DOS.
Is there an official guideline that I could give the Clinicians on this? Or how has anyone
else handled this? Would adding a clarifying statement be enough?
Hi there,

Unless they are counting time outside of what is allowed for the visit I don't see any cause for concern regarding the date of the signature. There was not - to my knowledge - a different rule for signing E/M charts under the 95/97 guidelines, when the provider could base the level on time using the counseling/coordination of care guideline and I haven't seen one for time under the new guidelines.

I'm certain auditors will continue to question (and deny) claims, but that doesn't mean they'll always be right. Everyone is still learning this system and practices will need to make sure auditors are applying the guidelines that were in effect on the DOS for the claims being reviewed.
 
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