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Thread: documentation

  1. #1
    Join Date
    Apr 2007
    New Orleans

    Question documentation

    AAPC: Back to School
    Can anyone tell me where I can find the date deadline for documentation completion for clinic notes. All help is appreciated.


  2. #2
    Join Date
    Apr 2007

    Default reference

    here is a link regarding E/M services guide.


    page 4 states "In order to maintain an accurate medical record, services should be documented during the encounter or as soon as practicable after the encounter."

  3. #3
    Join Date
    Apr 2007
    Kansas City, MO


    There is no "official" timeline, but like the above poster wrote, Medicare uses the term "soon". I have heard a medicare rep say they "recommend" it be 48 hours max, but that person also admits it is not an "official" number.

    We have an internal policy that it has to be done within 48 hours.
    Linda Vargas, CPC, CPCO, CPMA, CPC-I, CEMC
    PMCC Licensed Instructor
    Kansas City, MO Chapter
    Member Development Officer 2016
    Harrisonville, MO Chapter President - 2013
    ICD-10 Education Coordinator- 2012
    Chapter President - 2011
    President Elect - 2010

  4. #4
    Join Date
    Apr 2007
    New Orleans


    Thanks Ladies… I just have a physician that thinks they can be complete on his own time.

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