Physician Signatures

[geugene]

I have a fellow coder who stated that where she works they bill for dictated operative reports that have not been electrically signed by the MD. She states their practice is to submit the charge and flag for a signature. The operative procedure is dictated in 24 to 48 hours but a signature my take up to 45 days. In that order. I am not in agreement with this practice. I believe that coding compliance rules are being disregarded/broken.

My question: From a auditing stand point should they be submitting charges for an unsigned dictated report?

Thanks

[em2177]

Signature including credentials written or electronic must be documented.
Electronic signatures must be authenticated. A typewritten signature does not meet the signature requirement.
Thanks,

[bpct6501]

When we audit E/Ms, we don't consider them billable until there is a signature. I would agree with you that the signature is needed first.

[FTessaBartels]

Our practice will code and bill from a dictated operative report before it has been signed, as long as there is no inconsistency noted with the dictation (e.g. title says right inguinal hernia and report states left; or title states 3 procedures and body of report doesn't mention one of them). The unsigned reports are flagged and put into an electronic queue for the physician signature.

Of course, if there is any inconsistency noted, or missing information (e.g. size of lesion), the physician is notified, and those reports are held until corrected/ amended as needed.

When the physician him/herself has dictated the operative report, that is a good indication that the service was, in fact, provided.

Of course, we do not audit PRIOR to billing. Our audits are done retroactively.

F Tessa Bartels, CPC, CEMC