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Wiki Final Documentation?

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Cyndi113

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Good morning, Everyone!

Does anyone have any documentation or resources to determine when a visit is considered final? We are being asked for visit documentation by Medicare for an appeal. This visit was coded prior to my employment. I was asked to review it prior to our appeal. On the original documentation, the correct diagnosis was not included in the physician's impression and plan. I requested that it be included as a late entry (it was documented in the HPI and exam). However, this visit was completed in March. I read the most recent Medicare guideline from this July but it does not state how far back a physician may correct documentation.

Any advice?
 
To the best of my knowledge there is not cut off time for late entries. I have looked extensively for this information and I have never found it.

I would think in your scenario, it wouldn't be much of an issue since the info was already in the note it just didn't make its way down to the A&P. Its the late entries that are way off that concern me. You know the "Oh by the way I forgot to document the comprehensive exam needed to support this level so 8 months later I shall dictate it" kind of entries.

I'm a bit jaded today, lol, but I have researched and will continue to keep tabs on this issue, if I find anything else I'll be sure and post it.

Laura, CPC, CEMC
 
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