Medicare Documentation Signature Timeliness

Published 05/16/2022

Medicare providers must comply with documentation requirements, including the timeliness of documentation in connection with the provider signature.  Unless the documentation for a service is completed; including signature; a provider cannot submit the service to Medicare.  Medicare states if the service was not documented, then it was not done.

Providers 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." This statement is from the Centers for Medicare & Medicare Services (CMS) Internet-Only Manual (IOM) Publication 100-04, Chapter 12, (PDF) Section 30.6.1. 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.

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