In Coding
Sep 6th, 2016
Payers and the Centers for Medicare & Medicaid Services (CMS) require that the medical chart documentation sent to support a claim contain a legible and timely signature. For medical review purposes, Medicare requires the author, using a handwritten or a valid electronic signature, to authenticate the services provided/ordered. Regardless of how accurate the coding is, ...
In Audit
Jun 30th, 2015
By Charla Prillaman, CPCO, CPC, CPC-I, CCC, CEMC, CPMA All pro-active medical practices perform coding/billing audits; some by practice staff and others by an outside vendor. These audits are usually designed to identify and, if necessary, remediate any gaps between medical record documentation and CPT, HCPCS II, and ICD-9 codes used for claims submission. Recent ...
By: Diana Williams BS CPC CCS-P CCS CPMA The primary purpose of health record documentation is for continuity of patient care, and as a means of communicating among all healthcare providers. This clinical documentation captures the patient’s medical condition(s); hence, attention to documentation should be a priority for clinical providers. According to the Centers for ...
In Billing
Jul 14th, 2014
When billing for ambulance services, please note that the Centers for Medicare & Medicaid Services (CMS) recently made a couple of policy changes. Signature Requirements Effective August 12, 2014, a representative signing for ambulance services on behalf of a Medicare beneficiary does not need to include his or her address on the Form-1500. See Transmittal ...
Mar 1st, 2014
Compliance Without a valid signature, you risk payer reimbursement. By Susan Edwards, CPC, CEDC The purpose of a physician’s signature in a medical record or operative report is to clearly identify who ordered and provided supplies or services for the patient. It also serves as a testament that the services he or she provided were ...