We often get questions regarding charting deadlines related to Meaningful Use and MACRA/MIPS. Does my chart note have to be done in 24 hours? Does it have to be done within one year? The short answer is there is no 24 hour deadline, but documentation is best captured while the visit is fresh in your mind.
We like to share the following Medscape article from a healthcare attorney that answers these questions, citing the Medicare Claims Processing Manual.
The author states two good points.
- Medicare has no immediate deadline to capture your documentation, but you must bill within 1 year of the visit and you cannot bill until your documentation is complete (ie. signed).
- Documentation of a visit should be captured as quickly as possible to ensure accuracy and to avoid future liability.
The key word above is “capture” your documentation. When you use Fenton Transcription’s EMR Charting via Dictation service, you are performing your charting by dictating. In an ideal workflow, you have dictated all of your visits by the end of the day.
Even though there is no such thing as the 24 hour charting deadline, dictating your charts as you see patients accomplishes all of the following goals:
- Capture your visit information while it is fresh in your mind, reducing liability from forgotten information or scrutiny in compliance auditors asking why your charts weren’t completed days/weeks/months after the visit.
- Complete your charting process faster than both self-typing and voice recognition. You can dictate 200 words per minute. Median dictation length for providers using our EMR Charting service is under 2 minutes.
- Finish your work day with the comfort of having your charting done. No more after hours or weekend charting.
Here’s a link to the full article on Medscape. You may need to create a free Medscape account to read:
The author’s citations include links to CMS sources for the information.