Wiki How long does a doc have to complete a note?!

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apinto7434

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Hi everyone,

I am currently dealing with the issue that my physicians are taking wayyyy too long to finish a SOAP note.. (longer than 30 days) Anyone know where I can find regulations on how long a doctor has to finish a note before I can refuse to code it. I am currently going by 30 days and still struggling.. Would love to have it in writing to implement rules. Thank you in advance!! - Amanda
 
Where I am at, we have bylaws written requiring all hospital charts be closed within 7 days of discharge. However, our physician offices are not currently covered under that bylaw. You may want to point out to your physician that some insurance companies' filing limitations are as tight as 60 days, and he has the potential to lose revenue. I don't think as the physician's coder you can refuse to code charts. Regardless of age, a claim still needs to be filed whether it will deny for filing limation or not.
 
Thank you. I'm new to this, so bear with me! As far as I am aware, pertaining to meaningful use, soon physicians will have to finish notes within 24 hours. I work for a PCP (geriatrics) MSO- not fee for service. We use an EHR system that only sends encounters to Humana and we get paid based off diagnoses. Humana will accept claims but isn't it unethical for a doctor to do a SOAP weeks later? Our system will let you physically do it, but isn't there guidelines.. for example there's 30 days for an addendum to be done or it needs to be documented the next time the patient is seen. Who can I contact? thanks again!
 
I was told by a consultant that they have 30 days. Anything after that would be a non-compliance issue and not billable. Hope that helps!
 
Not that I'm condoning late notes but there is a difference between "unethical" and "illegal."

The guidelines are somewhat vague, along the lines of "as soon as possible" but check with your MAC and office/hospital bylaws. After that, you have to deal with carrier filing limits so be sure your docs are aware of the financial impact late claims will have.

They should also be reminded of providing the utmost care and how they would feel sitting on the witness stand trying to defend documentation put into the record months after the service.
 
Most regulations that address incomplete records (aside from Joint Commission, that state 30 days for hospital records) will defer to internal policies. Things like signing orders and notes, etc are dictated by policy more than regulation. If you don't have an internal policy that addresses it, you should have one developed.
 
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