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Documentation Timelines

January 27, 2013

Wisconsin Physician Services (WPS), a Medicare contractor, recently published this Q&A. The Q&A is applicable nationally.

Question: I am confused concerning the timeliness of my documentation in connection with the provider signature, submitting the claim to Medicare, the 30-day rule, and the timely filing rule. Can you provide more information?

Answer: There are several provisions that may affect "timeliness" when talking about documentation. The first is that a provider may not submit a claim to Medicare until the documentation is completed. Until the practitioner completes the documentation for a service, including signature, the practitioner cannot submit the service to Medicare. 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." 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 Internet Only Manual 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) ... "If a provider delays in recording (and verifying if transcribed) the documentation of a service, the accuracy of the documentation could be compromised."

The third is the 30-day information regarding 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. In addition, the Manual makes the statement "shall give less weight" when the documentation is created more than 30 calendar days after the service.

This 30-day rule may apply two ways. The first is when the practitioner does not complete documentation within 30 days of the service. In these cases, Medicare will not accept the documentation and could deny the service. The second is when the documentation shows it was completed at or shortly after the service, but the signature was not added. As stated above, do not add a late signature, but instead use the attestation statement. One misconception we have heard indicates that if the documentation of the service is completed more than 30 days after the service, the attestation statement will waive the requirement. This is incorrect.

The fourth provision is the timely filing limit. This does not apply to the medical record documentation but instead indicates that a practitioner has one 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.

The Q&A may be found at:

In addition to this Q&A, CMS recently published Med Learn Matters SE1237, which provides guidance for amendments, corrections, and delayed entries in medical documentation. The key points are (i) clearly and permanently identify any amendments, corrections, or addenda; (ii) clearly indicate the date and author of any amendments, corrections, or addenda; and, (iii) clearly identify all original content (do not delete).

Submitted by Deborah Lyman on February 24, 2013