Timely Completion and Signing of Medical Records

Coding Corner

The information provided here applies to Medicare coding. Be sure to check with your Medicare Administrative Contractor (MAC) for additional information and clarification on these and other items. You should also contact your local insurance carriers to determine if private insurers follow Medicare's lead on all coding matters.

Timely Completion and Signing of Medical Records
One concern I often hear from billing staff has to do with the timely completion of medical records.  This issue has both billing and compliance ramifications.  A recent Medicare seminar I attended provided some interesting information on this topic that I thought I would share with you this month.  
For billing purposes, Medicare generally requires the following:  
1. The medical record should be complete and legible.
2. The documentation of each patient encounter should include:

  • Reason for the encounter and relevant patient history, physical examination findings and prior diagnostic test results;
  • Assessment, clinical impression or diagnosis;
  • A plan for care; and
  • A date and legible identity of the observer.

While the issue of legibility has been largely addressed by increased utilization of electronic health records (EHRs), completion of the record through the inclusion of proper documentation and a dated signature continues to be of concern.  What does it mean for a medical record to be complete?  Is the record complete when it contains the documentation of the patient encounter but is not signed and dated?  As you know, you should not bill for an office visit or other service until documentation is on file supporting the level of service or code indicated for billing.  The file is not complete until the proper documentation is accompanied by a dated signature.  The question becomes, “How long do you have to sign and date the record in order for it to be accepted by CMS?”  The question is most important because EHR systems do not allow for back-dating of a signature.  As such, an auditor knows exactly when the signature of the provider was placed in the record.  How long is too long after the care is provided?

If you go to the website of your Medicare Administrative Contractor (MAC) you might find the answer.  The CMS/Medicare policy manual is specifically vague to allow the regional MAC’s medical directors the opportunity to set policy for their regions.  As a result, the answer as to timing varies from region-to- region.  CMS’s vague guidance is found in Chapter 12 of the Manual in the following statement, “The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record.” 
So what is your “requirement” for a timely signature?    Check with your MAC.  Some give reasonable direction, like WPS which states, “A reasonable expectation would be no more than a couple of days away from the service itself.”  Noridian states that they expect, “In most cases the notes would be signed at the time services are rendered.”  Palmetto is a little more direct stating, “Providers should not add a late signature to the medical record, (beyond the short delay that occurs during the transcription process).”  It is understood that there are circumstances, like waiting for transcription to be complete that might preclude signing the record at the time of service.  In general, it is best to sign the record at the time of service, if not within a day or two at the latest.

Signatures beyond a couple of days increase the likelihood that a claim will be denied because necessary documentation will not be accepted as being present due to a signature and date too removed from the time the care was provided.  This could be disastrous and costly in an audit.  For example, if every note that had a signature older than three days after the service was provided was not accepted by the MAC, then the provider’s documentation of work that was done at the time of the visit with the patient would not be allowed.  As a result, there would be no accepted documentation for the visit and payment would not be allowed even if an attestation statement was added at a later date.

To safeguard against these potential pitfalls, your practice should have policies that filing for services occur only after documentation is complete – including a dated signature.  This will give your billing staff guidance and keep their work compliant while holding yourself accountable for getting your documentation done in a timely fashion.  Most importantly, have a policy in place that that holds you and other providers in your office to a standard time period, perhaps 36 hours, to have a signature on the chart. These two policies will help ensure there are no compliance or billing issues caused by the lack of a timely signature.

Stay True to Why You Pursued Medicine.