Question Documentation Signatures

thelma

Networker
Messages
82
Best answers
0
I am asking this question because we are being pushed to get charges in faster. It was my understanding that charges could not be posted until providers verifies and signs his documentation.

Is it ok to have provider sign his dictation prior to editing and transcription, so charges maybe posted? Then when documentation is ready for editing or transcription the signature is removed, then transcribed or edited then sent back to provider for signature.
 

RyanRaichCPC

Networker
Local Chapter Officer
Messages
93
Location
Lawrence, KS
Best answers
0
It is advised to not bill until the dictation is signed. There is even CMS guidelines regarding this. The rationale behind this is that, what if your doc goes in and adds to the dictation? You have already billed out the charges, however, a new diagnosis may have been added, etc. that should be reported. Personally, I hold my billing for unsigned dictations and track them. Our organization has a timeline docs are supposed to follow regarding the timeliness of completing their dictations. Once a few days have passed I then email my doctor to inquire about the missing/unsigned dictations and I remain very consistent on following up to query my providers on any missing/unsigned documents.
 

thelma

Networker
Messages
82
Best answers
0
Thank you for confirming. The problem is that my practice and another Orthopedic office was recently acquired by a large Hospital. Our practice did not bill until Doctors signed and our coders reviewed, but the other practice post from a billing sheet with no verification done, belief is it can be worked at claims if denied.
 

Pathos

True Blue
Messages
614
Location
Beaverton OR
Best answers
1
I agree with Ryan. Once the chart is signed, then the chart is completed for ethical purposes. To have a process where the provider signs and then fully intends to add more later is risky business and could be viewed as fraudulent. CMS says that the only reason a provider should return to the chart is to correct mistakes or anything pertinent to the patient's treatment plan, and not for billing/coding purposes.


CMS Program Integrity Manual Ch. 3.3.2.4 - look also at 3.3.2.5 for Amendments, Corrections and Delayed Entries in Medical Documentation
CMS MLN Complying with Medicare Signature Requirements

Hope this helps!
 

thelma

Networker
Messages
82
Best answers
0
I agree with Ryan. Once the chart is signed, then the chart is completed for ethical purposes. To have a process where the provider signs and then fully intends to add more later is risky business and could be viewed as fraudulent. CMS says that the only reason a provider should return to the chart is to correct mistakes or anything pertinent to the patient's treatment plan, and not for billing/coding purposes.


CMS Program Integrity Manual Ch. 3.3.2.4 - look also at 3.3.2.5 for Amendments, Corrections and Delayed Entries in Medical Documentation
CMS MLN Complying with Medicare Signature Requirements

Hope this helps!
Yes it does thank you very much.
 
Top