General Surgery Coding Alert

Question: How can we make sure our surgeons meet signature requirements for charts and communications? Can we list each surgeon’s name at the bottom of each chart page and leave space for them to sign and date above their name? For lab results or other correspondence, can each surgeon use a printed-name/credential stamp and sign above it?

Michigan Subscriber

Answer: The surgeon can sign his office visit chart however he pleases, provided it’s over a written name with credentials.

You should also have a signature log on file in the office that includes any potential ways the physician could sign a chart or note. For example, Dr. Darren Smith sometimes signs his charts as “Dr. D. Smith,”“D. Smith, M.D.,”“D.S.,” or “Darren Smith, M.D.” The signature log must include each of those signatures or initials so you can provide the information to auditors as needed.

Caveat:The only exception would be if the applicable regulation, NCD, LCD, or payer manual has specific signature requirements. In that case, the specified requirements would take precedence.