Wiki Timely documentation


Greensboro, NC
Best answers
Does anyone know where I can go and find out what are guidelines for making sure that dictation is done in a timely manner? I have seen something before, and I think it was from CMS that dictation or documentation should be completed 48 hours from the patient encounter. This was referring to physician office visits. Any help would be appreciated, I have to talk with some physicians and they are having a problem in their practice with physicians not completing dictation for weeks.
Unless individual states have specific laws regarding timely documentation of medical services an organization that participates with Medicare must follow the conditions of participation guidelines. Some states have gone with a 48 hour rule, but you have to check with the individual state to see.

If a claim is submitted for payment and the documentation that supports the service is not present this would be cause for concern. In 2010, CMS applied the more stringent review criteria for measuring improper payments. The primary causes of errors in the program for 2010 are insufficient documentation and medically unnecessary services. The 2010 error rate of 10.5 percent is lower than the error rate of 12.4 percent that was calculated for the claims reviewed under the more stringent review criteria set in 2009. CMS is looking at documentation. If a claim is generated and payment is requested, the documentation to support it better be available.
Does anyone have any info regarding how long a physician has to dictate an operative note? We are having problems with physicians waiting up to a week to dictate.