Completing Medical records within a specified timeframe is essential for patient care, legal compliance, patient safety, reimbursement, and the overall functioning of the healthcare system. In fact, the success of medical coding outsourcing and in-house coding processes is dependent on coders’ access to timely and accurate healthcare documentation. In order to assign the correct codes for diagnoses, procedures, and services, the information in the patient’s medical records should be precise and complete.

So, what is the recommended timeframe for finalizing medical record documentation in the office setting? Medicare recommends that “the service should be documented during, or as soon as practicable after it is provided, in order to maintain an accurate medical record” (www.capphysicians.com). While the Centers for Medicare & Medicaid Services (CMS) does not define a specific period to indicate “as soon as practicable,” or “timely and reasonable”, some Medicare fiscal intermediaries (FIs) define 24-48 hours as a reasonable time frame.

Healthcare providers should adhere to this guideline when finalizing medical record documentation. Additionally, coders and personnel responsible for charge entry and submission should be mindful of the importance of timely medical record completion. Even physicians who are not Medicare providers should be aware that other payers and organizations tend to adhere to Medicare documentation requirements and recommendations.

Why Timely and Accurate Healthcare Documentation is Crucial

Although the process of “charting” in medical records may appear straightforward, it has many potential pitfalls. Before we discuss this, let’s take a look at the characteristics of good clinical documentation and why it is so important. A Physicians Practice article lists the features good clinical documentation as:

• Clarity
• Precision
• Consistency
• Timely
• Measurable

Ensuring that medical records are correct and completed within a specified timeframe is crucial for various reasons:

• High-quality patient care: Timely and accurate documentation is a fundamental aspect of delivering high-quality healthcare. When healthcare providers have access to up-to-date information about a patient’s medical history, diagnoses, treatments, and medications, they can make informed decisions about the patient’s treatment.

• Continuity of care: In a healthcare system where patients may see multiple providers and specialists, comprehensive and up-to-date medical records facilitate the seamless transfer of information between healthcare professionals. This continuity of care helps prevent medical errors, duplicate tests, and ensures that each provider has a clear understanding of the patient’s health status.

• Patient safety: Complete and up-to-date medical records help prevent medical errors, such as medication mix-ups or misdiagnoses, which can have serious consequences for patient safety. Healthcare providers can make better-informed decisions when they have access to a patient’s complete medical history.

• Insurance and reimbursement: Insurance companies often require detailed medical records to process claims and determine reimbursement for medical services. Incomplete or delayed documentation can result in delayed payments or claim denials, affecting the financial stability of healthcare providers and institutions. The OIG (Office of Inspector General, www.oig.hhs.gov) provides an illustration of inadequate documentation, wherein billing occurs without adequate supporting evidence in the medical record. In this example, a hospital submitted a bill to Medicare for various imaging services purportedly administered during the treatment of a Medicare beneficiary in the hospital’s emergency room.

Upon request for justification of these charges, the hospital provided the associated medical record, which pertains to the emergency room visit. However, crucial elements were conspicuously absent. Specifically, there was no mention of the x-rays for which Medicare had been billed. The key components missing from the record were: a comprehensive medical history and physical examination that would substantiate the necessity for the x-rays, a physician’s explicit order for the x-rays, an interpretation of the x-rays, and the outcome of the interpretation indicating that a qualified professional had reviewed the x-rays. Furthermore, there was no indication that the treating physician had incorporated the x-ray results into the patient’s care plan. These notable omissions leave critical gaps in the record.

When the OIG evaluates a record of this nature, it is impossible to determine whether the beneficiary genuinely required x-rays, whether the x-rays were indeed conducted, and, if conducted, whether they were subsequently evaluated.

In this case, although the hospital billed for these services, its documentation fails to substantiate its entitlement to retain the associated funds. Proper documentation practices could have averted this issue.

• Legal reasons: Healthcare organizations and practitioners are required by law and regulations to maintain accurate and complete medical records. Failing to do so can result in legal and regulatory consequences, including fines, sanctions, or even loss of medical licenses. An article published by the AAPC in June 2023 provides the following example on failure to document:

“One reported example of failing to comply with timely documentation of a patient encounter involves a physician who received an after-hours call from a patient complaining of a severe headache. The physician instructed the patient to go to the emergency room (ER) for an evaluation. The patient responded, “Okay,” but never went to the ER as instructed and had a massive cerebrovascular accident later that night. The patient subsequently sued the physician, alleging that the physician did not direct her to go to the ER. Her allegations were backed by a friend’s witness testimony. Unfortunately, the physician did not document the content of the phone call or her instructions to the patient. If the physician had simply documented the conversation, the physician may have avoided a lawsuit”.

Properly documented medical records can also provide legal protection for healthcare providers in case of malpractice claims or lawsuits. Thorough and timely documentation can serve as evidence of the care provided and the decision-making process.

• Communication and collaboration: Timely and effective clinical documentation primarily serves as a means of communication among healthcare providers is crucial. For clinical records to fulfill their intended purpose, they must be accessible to members of the healthcare team such as nurses, therapists, and other healthcare professionals, whenever necessary for the diagnosis, treatment, or monitoring of a patient’s condition. Timely completion of medical records enables efficient communication and collaboration among healthcare team members. It ensures that they have access to the most current information, enabling them to provide coordinated care.

• Medical billing and revenue cycle management: Accurate and complete documentation is essential for billing and revenue cycle management in healthcare organizations. Proper coding and billing rely on accurate descriptions of services provided, which are typically documented in the medical records.

Comprehensive and precise documentation is crucial for the provision of quality care while upholding the integrity of the healthcare system. Crucially, thorough, accurate, and timely documentation stands as a key player in ensuring that your patients receive the right care exactly when they need it. Commitment to excellence in documentation not only promotes patient safety but also acts as a powerful shield against potential malpractice allegations.

At our medical billing and coding company, we understand the fundamental role that meticulous and timely medical record-keeping plays in substantiating billed items and services, as well as facilitating appropriate reimbursement. To adhere to best practices, we encourage you to diligently complete and endorse charts within a 24 to 48-hour timeframe. By doing so, you not only enhance the quality of care but also strengthen the integrity of the healthcare ecosystem.