Finish Documentation on a Patient Visit Within 48 Hours?

Carolyn Buppert, MSN, JD

Disclosures

September 25, 2018

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Question

We received the following question from a nurse practitioner who functions as a primary care provider. The question and answer, however, apply equally to physicians, physician assistants, and advanced practice nurses.

My employer wants me to agree, in writing, to complete all medical records with 48 hours. Often, I see patients until I leave work on a Friday evening and then still need to spend 2-4 hours on documentation. If I must complete it within 48 hours, then my deadline is Sunday afternoon. That essentially precludes me from having a weekend off. Is this reasonable?
Response from Carolyn Buppert, MSN, JD
Healthcare attorney

I know of no payer who requires that documentation of office visits be completed within 48 hours of the visit. Medicare's Claims Processing Manual (chapter 12, §30.6.1.A) states: "The service should be documented during or as soon as practicable after it is provided in order to maintain an accurate medical record." Practices accredited by the Joint Commission will need to follow that organization's standards.

I think what is going on with your employer's requirement is threefold. First, the employer wants to be sure that the documentation is complete before the claim is submitted to the payer. The employer may want to submit claims for Friday visits on Monday morning. So, the employer wants documentation complete by Monday morning.

Second, the employer wants to be sure that documentation doesn't fall through the cracks. If you are seeing patients on Monday morning and still have visits undocumented from Friday, there is some chance that the Friday visits could be forgotten. In that case, there would be no documentation to support the visit. Auditors for Medicare and other payers ask a practice for medical records for specific patients who are provided specific services on specific dates. Usually an auditor asks for 30 patient records. If even two of those 30 records aren't complete, there is no justification for payment for those visits, and Medicare will hold that those two bills were submitted in error. Medicare extrapolates its audit data. If there are errors such that 10% of the audit sample was billed in error, Medicare applies the error rate to the total Medicare reimbursements to the practice for the year. So, two of 30 invalid claims can turn into a demand for repayment of significant revenue. The bottom line is that employers don't want any documentation to fall through the cracks.

Third, it is very difficult to remember findings, treatment plans, and instructions given to patients when the provider is recalling from memory things that happened days ago. If you are completing charts on Sunday evening or Monday, reconstructing what happened on Friday afternoon may be difficult and accuracy may suffer.

One solution to this problem is to end patient visits on Friday at 2 PM, except in an emergency. Then, you would have time to complete your documentation before you leave on Friday.

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