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    Wiki Signature on chart note

    Hello, I am trying to find something that supports what a "complete" document is and the need of a signature prior to billing. In the office, we are in disagreement on sending claims electronically to insurance companies. I say you need the provider to sign off on the report before billing...
  2. J

    Wiki 99211 - documentation requirements

    Trying to figure out 99211. Here’s an example: Patient comes to office with blood glucose logs. Their appt is scheduled with Nursing staff and a nurse reviews patient glucose logs and sees their numbers are too high. Nurse documents “as per Dr. X patient to increase insulin”. Nurse then signs...
  3. M

    Wiki Signature for Progress Notes

    I'm pretty sure i Know the answer to this but I want to see what everyone else thinks. If you have a group practice and the Physician is out on vacation so a nurse practitioner sees the patient and signs the chart i know this is "incident to." The ordering physician comes back from vacation 2...
  4. P

    Wiki Nurse Practitioner charts countersignature?

    Does anyone know if patient charts need to be countersigned by a physician? I just want to be sure that we are following current statutes or regulations. I am located in California. Thank you!
  5. L

    Wiki Observation e/m

    I was wandering, our Surgeon's nurse (who is qualified) saw a pt. and the done the H&P (short form, hand written). All our Surgeon did was sign at the bottom. My question is does he not have to document that he approves with findings, or is it ok for just the signature? We are a Critical...
  6. L

    Wiki Signatures required for encounter forms?

    Our physicians (all providers) do their chart notes after seeing a patient, then "code" their encounters on a separate form that is submitted to coders for review and code entry into our practice management system. The forms are filed and saved, but are not part of pt. charts. Is a provider...
  7. H

    Wiki Signature for H&P?

    I need help! I need to find documentation that spells out that a physician needs to sign a form written H&P. This H&P is the form used in the room with the patient which the physician then uses to dictate a typed version (which he signs). I feel silly asking help with this, but I honestly...