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Office notes

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stellerdobes:
Having a "discussion" with a physician I bill for.  He is a
PCP he is behind in some if his office notes.  I normally will
not bill if the note is not done and signed.  He is arguing that I can go ahead and submit the claims to the insurance company even if the note isn't done.  Opinions

Michele:
I do not believe that the notes MUST be completed before the billing can be submitted.  Most of our physicians send over the claim information and we have no way of knowing if the notes have been done yet or not.  In several cases I know that the physician is typically behind in completing their charts/notes.  I am not aware of any rule/law stating this must be done.  I would love to hear from anyone else if they know differently.

stellerdobes:
Thank you for your response.  I never could find anything one way or other. 
It's never been a problem before but I've never had a physician this behind on charts

kristin:
I don't think is so much an issue for the billing of the claims, as it is if for some reason an insurance company should request a treatment note, and it has not been signed in a timely fashion. For Medicare, they consider a reasonable amount of time to be 24-48 hours.

If Medicare does a ADR before payment on a claim, and the note sent in has been signed a week, two weeks, a month, etc. after the DOS, chances are the claim will deny.

I have billed for several providers in the past where they were horribly behind on signing their notes. Once I explained to them the potential loss of revenue, most of them suddenly found the time to get their notes signed within 48 hours.

PMRNC:
For coding purposes I would think the notes would be done, but many times we don't know if it's done. But when my clients sign their superbills or daysheets I am allowed to assume the notes have been completed and the claim is valid for me to bill. If his notes are ever looked at or an audit is done and his dates don't match up to the billing there could be a problem. I don't require the notes (nor really does any biller need them) to actually submit the claim.

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