teaching Physician

Would you bill for this visit?
Resident sees pt. TP documents attestation & note 7 days letter saying he saw & examined pt etc.

TP sees pt same day as resident but doesn't document until a few days later. Still ok to bill once he does?


  • This is interesting because I have encountered this happening in a recent audit I did; would be interested in other opinions. A week, in my mind was too long and if no additional information was documented, I did not give credit.

    Maxine Lewis, CMM, CPC, CPC-I, CCS-P, CPMA
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    Cincinnati, OH 45246

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  • IMHO, if this is consistent, it should be addressed and resolved. If it's an occasional event, and not systemic, then I'd allow a late signature attestation for both cases.


    Kris Cuddy, CPC, CIMC
    Healthcare Compliance Analyst
    Compliance Office
    Michigan State University HealthTeam
    East Lansing, MI
    Ofc: 517-355-4547
    Fax: 517-353-5292

  • I completely agree with Kris in the case of only a missing signature. In her situation, though it's not just a missing signature, rectifiable with a signature attestation being added to an already-documented note. I've seen some auditors give a pass to a late signature (now a signature attestation as late "signatures" are no longer allowed for the most part) being added to a note from months before, as adding only a signature/attestation simply required that the doc recognize his own handwriting on an old note (in the old days of paper charts), and this can be done long after the note was left.

    She's missing the actual TP note itself, which entry attests to and explains the extent of the TP's actual personal involvement in that particular visit. So instead of a signature, we’re talking about a late entry of a missing note. Adding a late entry requires actual recall of the details of the event, and auditors are much stricter as to what time period they think is reasonable to assume that a note is based on actual recall vs. realizing (or being told) the note is missing, having no idea how they actually participated with the resident on that particular visit, and just putting in a standard TP note "to make the billing folks happy."

    So what is that shortened allowed time frame for a complete TP note (which of course needs to be signed) vs. a missing signature-only? Medicare at the federal level doesn't say, though some individual MACs have floated 48 hours as their cut-off, which I think is reasonable in most circumstances. That said, in certain specialties such as Trauma, where the encounter involved life-and-death situations, I've realized that the docs are able to recall the specifics of what occurred more vividly for quite a bit longer than in other specialties. Even then, though, you must be careful, as it's not really what the docs are able to recall that's important, but what an auditor (or reasonable third party) believes the doc is able to recall after X days/weeks. I always suggest having a time frame identified as your organizational expectation, and only exceeding that rarely and with good reason.

    Seth Canterbury, CPC, CPC-I

    Clinical Data Quality Education Department

    University of Florida Jacksonville Physicians, Inc.

    653 West Eighth Street

    Tower I, Suite 606

    Jacksonville, FL 32209

  • Here is something I ran across a couple of weeks ago, while looking for info regarding timely documentation
    Documentation Timeliness
    Question: I am confused concerning the timeliness of my documentation in connection with the provider signature, submitting the claim to Medicare, and the timely filing rule. Can you provide more information?
    Answer: There are several provisions that may affect "timeliness" when talking about documentation and claim submission.
    The first is that a provider may not submit a claim to Medicare until the documentation is completed. Medicare states if the service was not documented, then it was not done.
    The second is that practitioners 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, 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.
    In addition, CMS has a statement in the IOM Publication 100-08, Chapter 3, Section discussing the requirements for practitioner signature, "Providers should not add late signatures to the medical record, (beyond the short delay that occurs during the transcription process) but instead should make use of the signature authentication process."
    The IOM Publication 100-08, Chapter 3, Section discusses late entries. A provider should never add a signature to a medical record after the times discussed above. If a practitioner does not affix a signature at the time of the service (also allowing limited delay due to transcription), then the provider may complete an attestation statement.
    CMS may, occasionally instruct the contractors differently than that stated here due to extenuating circumstances. WPS GHA will publish information to this affect when we receive notification.

    Mindy L Dowd CPC,CPMA
    Denver Arthritis Clinic
    200 Spruce St
    Suite 100
    Denver,CO 80230

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