Wiki coding unsigned notes

[SSweetland]

I know this has been posted previously but I am going to try for a better reference. The question was asked why we do not code a note prior to be signed. I thought at one time there was something with a Coders Liability that we should not code a unsigned note because the provider could change something prior to his signature. There are signature guidelines for a provider, a lot of interpretation of articles and the majority of the coders respond they do not code unless the note is signed because it is considered an incomplete note. I really need something in writing to stand behind our point of waiting for the signature before we code. A lot of the guidelines state if a record is submitted without a signature payers could allow and attestation or signature log, so this is leading me to think differently but still not convinced this is a safe practice. thank you for all your help
Sheila

 

[ellzeycoding]

I know this has been posted previously but I am going to try for a better reference. The question was asked why we do not code a note prior to be signed. I thought at one time there was something with a Coders Liability that we should not code a unsigned note because the provider could change something prior to his signature. There are signature guidelines for a provider, a lot of interpretation of articles and the majority of the coders respond they do not code unless the note is signed because it is considered an incomplete note. I really need something in writing to stand behind our point of waiting for the signature before we code. A lot of the guidelines state if a record is submitted without a signature payers could allow and attestation or signature log, so this is leading me to think differently but still not convinced this is a safe practice. thank you for all your help
Sheila

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Signature_Requirements_Fact_Sheet_ICN905364.pdf

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1419.pdf

https://med.noridianmedicare.com/web/jeb/cert-reviews/signature-requirements

Nothing about waiting to code before being signed, but services provided and orders generated are not valid or complete without a signature. Therefore submitting a claim on unsigned notes would be for an unauthenticated service or orders.

 

[SSweetland]

thank you for your response. I totally agree and have reviewed all your resources. I was just needing something from the coding legal or ethics to stand behind the principal of not coding a note until is was signed and considered a completed document.

 

[ellzeycoding]

Some risk involved if the note isn't finalized.... so let's say you code based on what's there with an unsigned note.

The next day, the provider reviews the notes and make material changes (or adds additional detail) that affects the actual code needed to reflect the services performed/provided.

You are unaware of these changes having coded based on the note at the time you coded the chart. You see the note is signed (not realizing the changes the provider made).

You file the claim is filed with erroneous or inaccurate CPT codes and charges.

All hypotheticals, but that's the worse case scenario.

There ARE times when codes are entered into the system, but the note/encounter isn't finalized. For example, in dermatology, charges are held pending pathology after a non-biopsy proven lesion removal to know whether to bill excision (or destruction) as malignant vs. benign. Code selection often depends on the lesion path. Happens all the time. Once path comes back , the path is filed in the chart, and claims filed.

 

[SSweetland]

thank you so much for your help. That is why we hold for signature now. The question was brought up why does a coder wait for signature and these are all good but I am surprised there is not a particular document that is in place besides internal policies for this particular topic.