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