Provider Documentation Guidelines: Delayed Entries Q&A
Provider Documentation Guidelines: Delayed Entries Q&A
Recently, we’ve had an influx of questions regarding compliance issues. And the proper protocol for handling delayed entries in provider documentation and acceptable time frames. YES HIM Consulting’s team of credentialed HIM experts is ready to help answer your questions on proper protocol and compliance issues. Contact YES today for our consulting services!
In our research, we’ve found that the Florida MAC, First Coast Service Options, Inc. (FCSO) has made a clear statement regarding these issues in their bulletin that had been published in the third quarter of 2006. Furthermore, these guidelines focus on professional fee coding. However, FCSO comments that these guidelines can apply to fiscal intermediaries as well: “The focus of this article is on professional services that are usually but not always billed to the carrier (Part B funds) as opposed to the fiscal intermediary (FI – Part A and B funds). However, the principles apply to FI services unless the Medicare manuals note specific differences.” In regards to states other than Florida, we suggest that you confirm with your MACs in terms of their respective guidelines.
Q. What is a reasonable amount of time for a delayed entry/addenda to provider documentation?
A. Per the FCSO bulletin, 24-48 hours is within a reasonable time frame.
Q. What is an acceptable reasoning for a delayed entry in provider documentation?
A. Per the FCSO bulletin, delayed entries within a reasonable time frame are acceptable for: “purposes of clarification, error correction, the addition of information not initially available, and if certain unusual circumstances prevented the generation of the note at the time of service.” The AAPC Legal Advisory Board expanded upon this idea in an article published in September 2007 by stating: “Addenda to the medical record should not be a normal practice—these should be the exception and not the rule.”
Q. Can a delayed entry help meet medical necessity?
A. Presently, FCSO is very clear on the purpose of delayed entries. Use them for clarification only. “Delayed written explanations will be considered. They serve for clarification only and cannot be used to add and authenticate services billed and not documented at the time of service or to retrospectively substantiate medical necessity.”
Q. What is the expected timeframe for documentation completion without a delayed entry?
A. Per the FCSO bulletin, “Medicare expects the documentation to be generated at the time of service or shortly thereafter.”
Next Steps
Not sure if your provider documentation is up to par? In summary, YES provides organizations with the most up-to-date clinical documentation auditing, consulting, and training services, in accordance with current regulatory requirements. Contact YES today!
