Chart modification after 48 hours- fraud?

I audit Medicare charts for complete md/ np/ pa documentation. Bills are dropped in 2 weeks after discharge. But if the documentation is missing that I have requested, I have to pursue the doctor for 45 days.

Agree with canchaser ... and if you think about it, physicians are sometimes completing dictation on charts more than 48 hours after the patient was seen in the ER.

I have to say, however, I would never "unchart" something that I actually did, like Foley insertion. There's no reason that admission orders can't be edited to reflect the fact that an intervention was already done in the ER prior to the patient being admitted ... and this seems like a much better solution than obfuscating (sorry - I love that word) who/where/when the intervention was performed.

You need to check your facilities policies and procedures. If that doesn't help you, then you need to check with your facilities risk management and or legal department. Believe me, they want you to do the right/legal thing in order to avoid lawsuits or fraud charges from medicare/medicaid/insurance companies etc. Don't be afraid to ask these guestions from the appropriate departments.

Adding an order for something that was done is one thing. Uncharting something that was done is something else entirely. Ain't happening.

I have had to correct charts. I don't feel it's fraudulant as long as it's something I actually did do and did not chart. If they asked me to chart something as a "CYA" that didn't happen, I would refuse.

the "...after 48 hours is fraud" thing is not true. charting that is fraudulent, meaning it's done with intent to mislead, can occur anytime, even in ten minutes.

changes in the medical record to reflect billing may or may not be fraud, depending on what it is and how it's done. i'm not a huge billing expert, but say, for example, there is a charge for use of an iv pump, hourly. suppose that pump went into service at noon, but somehow the billing started at 6am. changing the iv fluid administration record to say that it started at 6am would be fraudulent, because it would be documenting 6 hours of chargeable service that was not delivered.

there are standards for how you may change a chart record. you draw a single line through it, so it's still legible, and sign and date and time when you drew that line. then you note why. "charting on wrong patient." "medication not given." "charted on wrong date, see ... " mybrowneyedgirl and caliotter have it exactly right.

I don't know about the laws by state, but logically I don't think the time frame of the charting should matter. It's fradulent if it's fradulent, regardless of when charted, and if someone is telling you to chart something that is intentionally not accurate, that is fraud. But if they're getting on you to chart something you actually did, but forgot to chart you did, I know for a fact that waiting more than 48 hours does not make it fraud. Best example where I work are restraint audits - it's a single box we have to click on at the end of our shift saying we gave all the proper care and precautions for restraints during our shift. It's easy to forget to do at the end of the day, I've had to go back and chart that on a patient from a month before. I don't see why that would be considered fradulent. But that's the only documentation I've ever been asked to alter.

If it's true, it's not fraud. If it's not true, it's fraud.

Most EMR's allow up to 2 weeks to go back and chart. Thank goodness because with all the new billing laws, if it is not charted properly, you don't get paid. If you are the cause for the facility not getting paid, you will lose your job.

Thanks for the replies, I will talk to risk management.