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Documenting after visit

  1. Question Documenting after visit
    Medical Coding Books
    Where can I find supporting documentation to present to a provider, that all documentation should be complete before going on to the next patient?
    I know in my classes this was discussed, but I need hard copy documentation.


  2. #2
    Columbia, MO
    I knowof no such rule or documentation, however, the claim cannot be coded until the documentation is provided. Remember not documented not done.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    Flower City
    Entities may develop a specific timeline for providers to adhere to. Generally speaking a guideline is 24-48 hours after a visit. Some might want to require a shorter time period. Coding must be assigned after documentation is complete and billing should never be submitted prior to documenation completion.
    The following is from AHIMA:

    1. Timeliness of Entries

    Entries should be made as soon as possible after an event or observation is made. An entry should never be made in advance. If it is necessary to summarize events that occurred over a period of time (such as a shift), the notation should indicate the actual time the entry was made with the narrative documentation identifying the time events occurred if time is pertinent to the situation.
    2. Pre-dating and back-dating

    It is both unethical and illegal to pre-date or back-date an entry. Entries must be dated for the date and time the entry is made. (See section on late entries, addendum, and clarifications). If pre-dating or back-dating occurs it is critical that the underlying reason be identified to determine whether there are system failures. The cause must be evaluated and appropriate corrective action implemented.
    Marianne Wink, RHIT, CPC, ACS-EM

  4. Default Documentation with NP and collaborating physician
    What about when the provider and NP are rounding. Here is the question from the provider: When NP sees patients rounding like she did today and dictates her notes, what time frame do I have to sign off and do my own note indicating I reviewed her notes? Also I was curious if we leave town on a Thursday if I would round Thursday morning and NP did notes on Friday and I got on the computer over the weekend and signed off on her note would that be appropriate?

    Please help!

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