What is acceptable for correcting medical records/documentation and what is the time period allowed?
See via the attached link a previously published article regarding delayed entries and (from the July/August 2001 issue of the Medicare Bulletin): http://www.cignamedicare.com/partb/bltin/all/01bltin/01_4/forall/b0104b08b.html These are not Medicare regulations but would be our expectations on claim reviews. Please note these references state: • Medicare expects the documentation to be generated during the time of service or shortly thereafter. • Delayed entries within a reasonable time frame (24-48 hrs.) 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 medical record cannot be altered. Errors must be legibly corrected so that the reviewer can draw an inference as to their origin. These corrections or additions must be dated, preferably timed, and legibly signed or initialed. • Every note stands alone, i.e., the perf
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