Wiki Provider Queries

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SkyleeA

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Looking to find strong documentation on how post provider queries should be handled. Trying to find a time line to be completed by, and if we can hold against if not completed for incomplete chart deficiency?
 
This question gets asked a lot and here some great articles that will help you:

https://www.aapc.com/blog/23844-medical-record-entry-timeliness-what-is-reasonable/.
https://www.palmettogba.com/palmetto/providers.nsf/DocsCat/Providers~JM%20Part%20A~Medical%20Review~General~9VTLBC1017?open&navmenu=Medical%5EReview%7C%7C%7C%7C

In short, Medicare deems "24-48" hours as reasonable for completing medical documentation. From the CMS Claims Processing Manual, Chapter 12 - Physicians/Nonphysician Practitioners, Section 30.6.1 (https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf):

"Documentation should support the level of service reported. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record."​

Also, some states have laws regarding the timeliness of documentation, so you will want to check with your state. In terms of penalties for non-compliance, that would be dependent on your office policies and possibly the physician contract. It is advised that you consult with legal counsel before imposing financial/monetary penalties. Hope this helps!
 
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Here are some additional resources about timeliness of documentation from The Joint Commission (TJC) that I came across today that may be of assistance as well:

https://www.jointcommission.org/standards_information/jcfaqdetails.aspx?StandardsFAQId=840
https://www.gpo.gov/fdsys/pkg/CFR-2011-title42-vol5/pdf/CFR-2011-title42-vol5-sec482-24.pdf
https://www.jointcommission.org/standards_information/jcfaqdetails.aspx?StandardsFAQId=862&StandardsFAQChapterId=79&ProgramId=5&ChapterId=0&IsFeatured=False&IsNew=False&Keyword=

In short, the TJC recommends that operative reports and high risk procedures be documented "immediately". Most other records, the TLJ defers to organizational policy as long as it is no longer than 30 days.
 
The link to CMS didn't come through completely, so here is the full link: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf


JenniferB7 said:
This question gets asked a lot and here some great articles that will help you:

https://www.aapc.com/blog/23844-medical-record-entry-timeliness-what-is-reasonable/.
https://www.palmettogba.com/palmetto/providers.nsf/DocsCat/Providers~JM%20Part%20A~Medical%20Review~General~9VTLBC1017?open&navmenu=Medical%5EReview%7C%7C%7C%7C

In short, Medicare deems "24-48" hours as reasonable for completing medical documentation. From the CMS Claims Processing Manual, Chapter 12 - Physicians/Nonphysician Practitioners, Section 30.6.1 (http://www.cms.gov/Regulations-and-G.../clm104c12.pdf):

"Documentation should support the level of service reported. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record."​

Also, some states have laws regarding the timeliness of documentation, so you will want to check with your state. In terms of penalties for non-compliance, that would be dependent on your office policies and possibly the physician contract. It is advised that you consult with legal counsel before imposing financial/monetary penalties. Hope this helps!
Click to expand...
 
Hi All,

Please keep in mind that the Joint Commission is a voluntary accreditation and unless the entity has a "deemed" status then the CMS regulations and guidelines apply. I would review the Conditions of Participation for Hospitals and other applicable guidance from the CMS website.

Josie
 
please clarify addendums

I've read through this post and I am looking for some guidance.

If ER physician did not document an exam or HPI (I know that is a problem), would it be appropriate to send the physician a query to add a late entry/addendum? This would occur the next day not weeks later.

I've look at the links listed in the thread and have tried to find solid information on this. All the information I find is about timeliness. The ER charts are locked after 48 hours here at our facility but it does not address the issue of sending queries.

One person in management says, "due to missing physician documentation we cannot query for additional information in order to assign a higher level. CMS considers this leading." How is it leading if I am asking the doctor to complete the documentation? I am not leading, merely stating---Dr. ???? in your ER note you are missing documentation on ????. ( the physician has not documented anything for the portion I am querying.) I would not send a query even if the physician put one element so I am not leading.

How would the 3.3.2.5-Amendments, Corrections and Delayed Entries in Medical Documentation be implemented then?
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/pim83c03.pdf

I've asked other coders and there reaction is, "it is not leading to ask them to complete the documentation."

In addition, in one of AAPC's training programs it is stated, "An addendum to include information about what was done to the patient, or any test results, should be added within a reasonable time frame, usually capped at a maximum of 60 days after the encounter."

Please tell me what you think. The new management does not provide information to clarify there statement.
 
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