Awareness : Did You Know? 2015-2016

Did You Know? Weekly Educational Series 12

For the Week of November 9, 2015

There are several provisions that may affect “timeliness” when talking about documentation.

The first provision is that a provider may not submit a claim to Medicare until the documentation is completed. Until the physician/practitioner completes the documentation for a service, including signature, the physician/practitioner cannot submit the service to Medicare for payment.

The second is that physicians/practitioners are expected to complete the documentation of services “during or as soon as practicable after it is provided in order to maintain an accurate medical record.”  This includes the signature. This statement is from the Centers for Medicare & Medicare Services (CMS) Internet-Only Manual (IOM)  Publication 100-04, Chapter 12, Section 30.6.1 CMS does not provide any specific period, but a reasonable expectation would be no more than a couple of days away from the service itself.

In addition, CMS has a statement in the IOM Publication 100-08, Chapter 3, Section 3.3.2.4 discussing the requirements for physician/practitioner signature, “Providers should not add late signatures to the medical record, (beyond the short delay that occurs during the transcription process), but instead should make use of the signature authentication process.”

The IOMPublication 100-08, Chapter 3, Section 3.3.2.5 discussing late entries. A provider should never add a signature to a medical record after the times discussed above.