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Thread: Documentation requirements

  1. #1
    Join Date
    Apr 2007
    Springfield IL

    Default Documentation requirements

    AAPC: Back to School
    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. #2
    Join Date
    Apr 2007


    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
    Join Date
    Apr 2007
    North Carolina


    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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