HELP! Acceptable Provider Signatures on Documentation

Misdavis

Contributor
Messages
18
Best answers
0
:confused:First of all, from the CMS regulations that I have read it is never acceptable for one provider to sign off FOR another provider. Also, completing documentation without a signature and submitting for billing is not acceptable. Medicare does not outline an exact time frame of what is appropriate. How delinquent is too delinquent (concerning signatures):confused:

Can someone give me their spin on this because when I read this, it contradicts the other regulations. It's about as clear as mud to me. It makes it sound like a provider could have an appointed person such as a MLP sign off for them as long as the provider and MLP aware that they are both legally bound to that record and that it is accurate?


https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/pim83c03.pdf


E. Electronic Signatures Providers using electronic systems need to recognize that there is a potential for misuse or abuse with alternate signature methods. For example, providers need as ystem and software products that are protected against modification, etc., and should apply adequate administrative procedures that correspond to recognized standards and laws. The individual whose name is on the alternate signature method and the provider bear the responsibility for the authenticity of the information for which an attestation has been provided. Physicians are encouraged to check with their attorneys and malpractice insurers concerning the use of alternative signature methods.
 

Chelle-Lynn

True Blue
Messages
729
Location
Modesto, CA
Best answers
0
The basic CMS guideline for documentation and signature is as follows:

All entries in the medical record must be dated, timed, and authenticated, in written or electronic form, by the person responsible for providing or evaluating the service provided

So in response to your question, no; one provider should not be signing another providers documentation. The signature should be from the provider who provided the service and evaluated the patient.

In regards to what is a reasonable timeframe...this is a little more tricky. CMS has not specified a timeframe other than to say what is "reasonable". This reasonable standard has been the subject of much debate over the years and is still on-going. What is generally recommended is that your agency, facility, office, etc set a standard for what is reasonable. Such as 5 days, 1 day, 20 days, etc. Once this standard is set then your compliance officer can work with you to educate the physician on what the acceptable standard will be for your organization.

In addition, the claim should not be billed until the provider has completed and signed their documentation. A provider signature is required to acknowledge that the service was rendered and documented to the best of the providers ability and knowledge. When we bill a claim we are in essence signing the claim form (whether hard copy or electronically) stating that the provider is certifying that they rendered and documented the services as billed.

Remember, all medical coding is just another language (congratulations...you are bi-lingual!). We are translating the documentation from the provider to a code based language to communicate with the insurance carrier about what services were rendered in order to receive payment. Without the provider signature the documentation is not finalized or verified.
 

Chelle-Lynn

True Blue
Messages
729
Location
Modesto, CA
Best answers
0
Yes it does. While a scribe will document the visit, the physician signature is indicating that the documentation is valid and accurate. Again, this is based on the physicians memory of the services and needs to be completed in a reasonable timeframe as well. The physician signature is a part of the documentation and needs to be completed timely.
 
Top