Kids Health First received guidance from Curi and our broker, Sterling Seacrest Pritchard, to share with practices. They state, “We are not aware of any requirements related to medical record completion; however, please reference the guidance from Medicare. Although Medicare is not the most common payor for pediatric patients, we reference this as it is instructive of the view from federal payors.”
Medicare providers must comply with documentation requirements, including the timeliness of documentation in connection with the provider signature. Unless the documentation for a service is completed, including signature, a provider cannot submit the service to Medicare. Medicare states if the service was not documented, then it was not done.
Providers 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 statement is from the Centers for Medicare & Medicare Services (CMS) Internet-Only Manual (IOM) Publication 100-04, Chapter 12, (PDF) 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.
Click to read more about Medicare Documentation Signature Timelines
Curi’s guidance is as follows:
Is there a time frame within which we are required to complete documentation in a patient’s medical record?
To keep the information fresh and accurate, the patient’s record should be completed as soon as possible after each encounter. We recommend a turnaround time of one business day (24 hours). This policy can help ensure that medical records remain available and are complete for the patient’s next visit or telephone call, and it improves the credibility of the dictation.
However, we recognize that a 24-hour turnaround time is not always practical. Your practice should set a standard that realistically can be met by all providers. A reasonable maximum turnaround time is three business days (72 hours). Note, however, that your policy is only as good as your practice’s adherence to it. For the policy to be effective, compliance should be monitored.
An additional consideration is the development of a timeframe is the 21st CURES Act. Under this law, an unreasonable delay in the patient’s ability to access their notes could be considered information blocking. Read more here.
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