Chart Signature

cpclori

Networker
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Seacoast-Dover NH
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Hospital administration is looking for official documentation that a chart must be signed prior to chart being coded. Can anyone help direct me on this?
Thanks in advance! Lori
 

cpclori

Networker
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37
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Seacoast-Dover NH
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OK, thanks. I am working on this as I wait for possible replies as well, and will post if I find any answers.
Hoping someone will be able to assist with this
 

LRKoschoreck

Networker
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Baltimore East, MD
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You can find this guidance on pages 3 & 4 of the MLN Evaluation and Management Services Guide:

"There are general principles of medical record documentation that are applicable to all types of medical and surgical services in all settings. While E/M services vary in several ways, such as the nature and amount of physician work required, the following general 4 Evaluation and Management Services Guide principles help ensure that medical record documentation for all E/M services is appropriate:

❖ The medical record should be complete and legible;

❖ The documentation of each patient encounter should include:
• Reason for the encounter and relevant history, physical examination
findings, and prior diagnostic test results;
• Assessment, clinical impression, or diagnosis;
• Medical plan of care; and
Date and legible identity of the observer."

The CMS Signature Requirements also imply that documentation must be signed before billing, but doesn't say it specifically anywhere (that I found).
 

aimie

Networker
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65
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Spring Hill
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Signature requirements

On the Medicare learning network there is a fact sheet called signature requirements. On the home page in the search box that's what I typed in and the first article was fact sheet. I hope this makes sense private message me and I can email you the fact sheet.

Aimie
 

gayle05

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Mentor
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unsigned progress notes

I was also trying to find out about progress notes being signed before submission. Our office is now using EMR. The doctor is filing out the superbill and locking it and wants me to submit the claim but the notes are not being signed, because she has to review EVERYTHING. The fact sheet for "Complying with Medicare Signature Requirements" states if signature is missing from medical record a attestation statement can be submitted, I am assuming if medical records are being requested. It also stated providers should not add late signatures to medical record, (beyond short delay for transcription process) but use signature authentication process.

Can I submit w/o signature? (I do not want this coming back on me, I do not think they would back me up)
Can she sign notes a month later(a month is good she's backed up a few months) or should I have a attestation statement on file for that DOS? Does the attestation statement have anything to do with my situation?

Any input would be great.
 

skh_fla

Contributor
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As an auditor I can tell you that signing a month later would be a red flag and no signature at all means no payment. The doc will either need to review right away and sign or set it up so that the bill doesn't get submitted until the record is signed off on.
 
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