Wiki Locking the EHR

[vickiestaack]

All,

I know this has been posted before, however I need help! Our providers state that CMS allows 72 hours to lock the electronic medical record. I say as a CPC it is 48. Is there a best practice on this? If so would someone please direct me?

Thanks
VStaack

 

[Pam Warren]

There's no hard and fast rule that I'm aware of. CMS says "timely" completion of records, and AHIMA recommends there be organizational policies in place regarding 'locking' an EHR after a certain amount of time, for example 24-72 hours. We allow 72 hours. Where (as a CPC) did you find the rule about 48 hours? I'd be interested to know.

The best practice states simply that you have a written policy. Most organizations I know of have 48-72 hours, but your providers are correct in that they can go 72 hours.

 

[vickiestaack]

Pam,

Thank you for your response. I took the CPMA course back in 2009 and there is a page that states "according to CMS all medical record entries must be signed and dated within 48-72 hours of the encounter." I have searched high and low and cannot find this exact passage.

 

[Pam Warren]

In the 2012 CPMA study guide, it states on page 2.8
According to CMS "all medical record entries should be signed and dated, usually within 48-72 hours of the encounter but certainly before the claim for services is filed"
It isn't giving reference where to find this in CMS, and this appears to be a suggestion for 'best practice', rather than regulatory guidance.