Awareness : OBC Tips

Timeliness of Documentation

There are several provisions that may affect “timeliness” when talking about documentation. A provider may not submit a claim to Medicare until the documentation is completed.

Until the practitioner completes the documentation for a service, including signature, the practitioner cannot submit the service to Medicare. Medicare states if the service was not documented, then it was not done.

The second is that 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.” 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.