Wiki HELP!!! Billing E/M without finishing note

[aproctor11]

Help! I need answers or at least confirmation!

I recently started a new position in a new company. The one physician owner is requesting that we bill out his E/M services without him signing off on the note. I have told him that I absolutely refused, due to guidelines. However, it was brought up by our PM company, for us to bill strictly off of the superbill, because it has a signature (which is illegible). I informed them of CMS signature guidelines.

I am at a loss going up against a PM company and my physician owner, at a brand new job.

WHAT SHOULD I DO!!!

 

[CodingKing]

My only guess is to start looking for a new job. If you cant prove your point with the evidence in front of them, I don't see it going well.

 

[mitchellde]

From comparing super bills to chart notes, I find that all too often they do not match or even come close. Maybe you should do some comparisons to show. You need a signed note. The signature on the note lets you know the provider has completed the document and no further info can be added. The claim is your legal attestation that the codes you have selected match the documentation. I can give multiple real examples of times when a super bill was used and the note was not signed. The claim was submitted, the patient complained about the EOB showing charges for services not rendered, the provider quickly changed the note and then signed it making it look as though the super bill had been incorrectly marked. This was found with an IT trace on when the note was accessed. There are several similar instances. They need to be aware that a finalized signed note is the only way you can be certain the provider has completed the visit.