What's Medicare's Deadline for Charting?

Carolyn Buppert, MSN, JD

Disclosures

August 28, 2014

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Question

Not having enough time to chart at work has left me extremely behind on charting. Is it true that Medicare accepts documentation up to 1 year after the patient service?

Response from Carolyn Buppert, MSN, JD
Healthcare attorney

A nurse practitioner writes to Medscape about how to solve a "late charting" dilemma:

Until 6 months ago, I was practicing in a clinic that serves patients with mental illnesses. I got behind on my charting and then I was sick and had to be out for a month. When I was ready to come back to work, they fired me. (I have an attorney looking into whether they had legal justification for doing that.) I told them a long time ago that I was worried about the late charting and now, months later, they have agreed to pay me for a set number of hours to complete the charting. I have heard that Medicare will accept charts for billing up to 1 year later if a letter is written explaining the delay in submission. I have justification: The clinic was understaffed medically, so I couldn't write the notes during the day, and my supervisor didn't want me staying after hours because the neighborhood where the clinic is located is unsafe. And then all was delayed when I was out sick. Can I get into trouble by writing up my charts at this point?

Medicare does not have a policy allowing providers to document up to a year later. Medicare expects documentation to occur at the time of the visit or very soon thereafter. No clinician can remember, accurately, what happened last week, and certainly not 6 months after a visit. Here are Medicare's policies on timeliness of documentation:

A provider can't submit a claim for payment until documentation is completed. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record.[1]

The Centers for Medicare & Medicaid Services (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.[2]

...[T]he timely filing limit...does not apply to the medical record documentation but instead indicates that a practitioner has 1 year from the date of service to file the claim to Medicare. If Medicare does not receive the claim within that year, Medicare does not make payment and the patient is not liable.[2]

So, although a provider has a year to submit a claim, the documentation should have been done at the time of the visit. The long time that Medicare gives for submission of claims is an option because Medicare sometimes takes a long time to credential providers and tries to accommodate providers by allowing them to batch-bill after they receive their provider numbers.

What should you do now? You can complete the records to the best of your ability. If you can't remember what occurred, don't make it up. That would be fraudulent and you could get into trouble. If you remember seeing the patient but don't remember what you or the patient said, what you did, or what you told the patient, then write that you remember seeing the patient but don't remember the details. Enter the date that you are recording the documentation and note the date that you performed the service. On each note, state why the documentation is so late. Your employer may or may not feel comfortable submitting claims for those visits. If they do submit the claims, and Medicare audits, Medicare may deny payment.

The take-home message for other nurse practitioners is: Complete your documentation within 24 hours after the visit. Late documentation is difficult to defend, both for billing purposes and in a court of law if you are sued. All clinicians following you in caring for the patient are at a disadvantage, because they have no way of knowing what you did for the patient. If a time comes when you find that you are more than 24 hours late with your documentation, speak with your employer about it. The employer should help you determine what is causing the delay and make some accommodation. For example, an employer might allow a nurse practitioner to stop seeing patients at 4:00 PM to complete his or her documentation between 4:00 and 5:30 PM.

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