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Documentation requirements

  1. #1
    Default Documentation requirements
    Medical Coding Books
    I was trying to find any articles or something from CMS regarding the requirements on what is the maximum allowable time from the time the patient is seen until dictation or documentation has to be completed. Or what are your thoughts on this? Thanks!

  2. Default
    I don't think you're going to find any CMS guidelines on this. The concern is the provider forgetting the info and trying to remember what was done to the pt. I've compared physician documentation from memory and cheat sheet documentation and have found that providers will usually forget something they did when dictated later w/o a cheat sheet.

  3. #3
    Location
    North Carolina
    Posts
    3,126
    Default
    I recommend that you contact your local carrier. They may have something in writing. My carrier:

    Documentation Pointers

    "Medicare expects the documentation to be generated during the time of service or shortly thereafter."

    Vague? Yes...

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