Author Topic: Office notes  (Read 301 times)

stellerdobes

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Office notes
« on: July 11, 2017, 04:22:46 PM »
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

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Re: Office notes
« Reply #1 on: July 12, 2017, 08:41:35 AM »
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.
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stellerdobes

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Re: Office notes
« Reply #2 on: July 12, 2017, 11:59:29 AM »
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

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Re: Office notes
« Reply #3 on: July 12, 2017, 03:10:52 PM »
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

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Re: Office notes
« Reply #4 on: July 13, 2017, 07:04:03 AM »
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.
Linda Walker
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rdmoore2003

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Re: Office notes
« Reply #5 on: July 13, 2017, 03:22:57 PM »
KRISTEN,
 DO YOU HAVE A LINK ABOUT THIS FROM MEDICARE??
Regina

kristin

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Re: Office notes
« Reply #6 on: July 14, 2017, 08:16:28 AM »
Regina, here are several links:

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Signature_Requirements_Fact_Sheet_ICN905364.pdf

https://www.aapc.com/blog/23844-medical-record-entry-timeliness-what-is-reasonable/

The first one mentions the note being signed allowing for a short delay in the transcription process, the second one clarifies what Medicare considers to be a short delay (24-48 hours)

rdmoore2003

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Re: Office notes
« Reply #7 on: July 14, 2017, 09:17:24 AM »
Thanks so much, Kristin.
Regina

PMRNC

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Re: Office notes
« Reply #8 on: July 15, 2017, 04:50:23 PM »
Sometimes I have to revisit the file for something like an appeal. I DO look at the office notes, date of service and billed date I have. IF it's something I need to send notes for I MIGHT tell a provider who was late with his notes, that he screwed up my appeal  :o  Normally I don't have a problem as my clients are PRETTY good with getting their notes and signing them before I bill them out. If it's something also I know the carrier might question, I'll hold the billing to ask the provider if his documentation is in order.
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com