Results 1 to 5 of 5

full dates on op notes

  1. #1
    Default full dates on op notes
    Medical Coding Books
    Can someone please tell me what Medicare states about documentation guidelines for writing the full date (with the current year) on all E/M and op notes? I have argued w/ a few people that the year must be included.

    I appreciate it.
    Malama pono,

    Sundae Yomes
    CPC, CPMA, CEMC, CGIC, CGSC, CCS-P

  2. Default
    Why would you not want to add the year? My guess is that it wouldn't hold up to an audit without the year.

    ~L
    CPC, CGSC, COSC

  3. #3
    Location
    ENGLEWOOD/DENVER
    Posts
    2,338
    Default
    also sounds like a transcription issue

  4. #4
    Location
    Duluth, Minnesota
    Posts
    1,133
    Default
    seems silly not to put a year on the documentation. I've actually gone into my own provider same day, two years apart (I remember, cuz it was my birthday both times) yeah - not fun birthdays those years! LOL... BUT - what confusion there could be if the date isn't complete. I think any insurance company, not just medicare will frown upon not having complete documentation - including "date of service". I agree with Treetoad also, if it was audited, it's not going to go over well!~
    Donna, CPC, CPC-H

  5. #5
    Default
    well, here's the problem. On the trauma rounds/initials, the pt's sticker w/ the admit date is on, so therefore, some people feel that you need to use common sense where this is. My whole arguement is, why are you being lazy? just use the whole date, which includes the year. I know of someone who bills for a hospital on the east coast that allows there billing to go thru w/out the year. I was just curious as to where there was documentation on the need for the year to be documented.
    Malama pono,

    Sundae Yomes
    CPC, CPMA, CEMC, CGIC, CGSC, CCS-P

Similar Threads

  1. Admit & Discharge dates vs Dates related to services
    By MFMcoder in forum Billing/Reimbursement
    Replies: 1
    Last Post: 07-11-2012, 07:56 AM
  2. Doctor Notes Vs Nurse Notes
    By SJones52 in forum Medical Coding General Discussion
    Replies: 0
    Last Post: 04-04-2012, 04:43 PM
  3. Electronic Notes WITH handwritten notes
    By Debbie C in forum Auditing General Discussion
    Replies: 1
    Last Post: 06-29-2010, 11:33 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
  •  
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?

Login

Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.