Wiki Outpatient workflow question: Do your physicians sign their note before or after coding review?

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stephanie040r@aol.com

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Hello,

My colleagues and I are designing processes for a new organization. Please give us some insight on when your physicians sign their note. Do they sign the note before or after coding review?

Thank you in advance,
 
stephanie040r@aol.com said:
Hello,

My colleagues and I are designing processes for a new organization. Please give us some insight on when your physicians sign their note. Do they sign the note before or after coding review?

Thank you in advance,
Click to expand...

I only code signed notes. If it's not signed, how do I know it is complete and accurate?
 
I agree with @amyjph and @sls314 that services should not be coded until documentation is complete. If it is not signed, it is not complete.
The determining factor for when a physician signs a note should be immediately after completion.
I cannot imagine a scenario in which you would want a process where the note is not signed until it is coded.
 
stephanie040r@aol.com said:
Hi amyjph,

Can you elaborate on your comment so I can better understand? What should be the determining factor for when a physician signs the note? What is your experience with coding notes after the physician has signed the notes?
Click to expand...
1. The facility or practice should/would have a policy and procedure for authentication of documentation which would be independent from anything to do with coding, billing or revenue.
2. Notes are not complete/billable until signed by the rendering provider or other authorized individual providing the service. Scenario: you bill it before signature, payer requests records, provider has not signed, unsigned records are submitted to payer, claim denied. Scenario: you bill it before completion/signature, the provider changes something, incorrect coding/billing, provider signs after billing, payer requests record - denied.
3. There should be a process for provider queries should the coder or individual billing find an error, omission or issue with the documentation. There should also be a policy on corrections and addendums.
4. Billing before signature and authentication puts the practice at risk.
5. This is also a medical/legal medical record issue, not just revenue related.
6. Can a practice do this? Yes. Why would they want to add more risk though? Can it be appealed, can there be attestations? Yes. Why would you want to go through all that and have to appeal and/or in bigger cases end up in court? The dang note can just be dictated and signed in a timely manner! Can you tell I have had fun times with this over the years? :)

Resources and examples:

"Unsigned medical records are considered unauthored notes and therefore do not constitute a billable service. With the prevalence of EMRs, many electronic signatures are not in compliance with the standards set by the Centers for Medicare & Medicaid Services (CMS)."

Look at some of the CERT reports and the unsigned/unauthenticated issues: https://www.cms.gov/data-research/m...ehensive-error-rate-testing-cert/cert-reports
Individual payers and state Medicaid plans may have other/additional rules.

My experience with physicians signing notes late is that they get their privileges suspended at facilities for being habitually late, the practice stops scheduling patients (in some cases), and there is a high compliance risk along with monetary in the form of take-backs, ADRs, and audits/denials. This is in addition to opening up to other medical-legal issues with documentation being poor, lacking detail and not being signed timely.
48-72 hours should be the maximum lag time. These late signers also have historically longer lag times, days in A/R and more record requests and audit issues (generally). They are also the providers that do not even dictate or document in a timely manner on top of the signature problem.

This was an interesting discussion about it with an attorney viewpoint: https://racmonitor.medlearn.com/to-sign-or-not-to-sign-a-provider-s-responsibility/
 
amyjph said:
1. The facility or practice should/would have a policy and procedure for authentication of documentation which would be independent from anything to do with coding, billing or revenue.
2. Notes are not complete/billable until signed by the rendering provider or other authorized individual providing the service. Scenario: you bill it before signature, payer requests records, provider has not signed, unsigned records are submitted to payer, claim denied. Scenario: you bill it before completion/signature, the provider changes something, incorrect coding/billing, provider signs after billing, payer requests record - denied.
3. There should be a process for provider queries should the coder or individual billing find an error, omission or issue with the documentation. There should also be a policy on corrections and addendums.
4. Billing before signature and authentication puts the practice at risk.
5. This is also a medical/legal medical record issue, not just revenue related.
6. Can a practice do this? Yes. Why would they want to add more risk though? Can it be appealed, can there be attestations? Yes. Why would you want to go through all that and have to appeal and/or in bigger cases end up in court? The dang note can just be dictated and signed in a timely manner! Can you tell I have had fun times with this over the years? :)

Resources and examples:

"Unsigned medical records are considered unauthored notes and therefore do not constitute a billable service. With the prevalence of EMRs, many electronic signatures are not in compliance with the standards set by the Centers for Medicare & Medicaid Services (CMS)."

Look at some of the CERT reports and the unsigned/unauthenticated issues: https://www.cms.gov/data-research/m...ehensive-error-rate-testing-cert/cert-reports
Individual payers and state Medicaid plans may have other/additional rules.

My experience with physicians signing notes late is that they get their privileges suspended at facilities for being habitually late, the practice stops scheduling patients (in some cases), and there is a high compliance risk along with monetary in the form of take-backs, ADRs, and audits/denials. This is in addition to opening up to other medical-legal issues with documentation being poor, lacking detail and not being signed timely.
48-72 hours should be the maximum lag time. These late signers also have historically longer lag times, days in A/R and more record requests and audit issues (generally). They are also the providers that do not even dictate or document in a timely manner on top of the signature problem.

This was an interesting discussion about it with an attorney viewpoint: https://racmonitor.medlearn.com/to-sign-or-not-to-sign-a-provider-s-responsibility/
Click to expand...

Thank you! This information is helpful. What is your experience with coding notes BEFORE the physician has signed them?
 
stephanie040r@aol.com said:
Thank you! This information is helpful. What is your experience with coding notes BEFORE the physician has signed them?
Click to expand...

You'd need to be sure to have a process to hold the claims until the notes are signed - you don't want to bill claims with unsigned documentation.

You'd also want to have a process to review the coding after the documentation is signed in case something changes when the provider finalizes the documentation.

That being said, I wouldn't recommend it. Why have the coding and billing staff touch each claim 2-3 times before it even goes out the door? That's a waste of your staff time and resources.

The goal should be to get a clean claim out of the door with as few touches as possible. It costs money every time a staff member has to touch a claim. It would be counter-productive to design a process that required multiple reviews before billing.
 
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