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Late entry

  1. #1
    Question Late entry
    Medical Coding Books
    Are there penalties for entering a note late?

    Donna E. Young, CPC

  2. Default
    What do you mean by penalty? A late entry should be made as soon as the omission is realized. However, the author must have clear recollection of the event. So there may not be a penalty but if the note is written say 3 months after the fact, the reliability of the note may be put into question. This may mean denial of payment or if it is a legal case the entry may be disregarded and may put the entire record keeping practices in question.

  3. #3
    Thanks for the info. I guess I am also wondering if we catch the late entry before the bill is submitted if we should even submit the claim? For example if the note is entered a month after the patient is seen is it okay to submit? I work at a teaching facility and the resident will see the patient, enter their note, the supervising attending Dr may not enter their part of the note until much later. This isn't common practice. Mainly it's only a problem with 1 of our physicians.

    Donna E. Young, CPC

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