Wiki Incomplete Dictation Question--HELP!!!!

[LewinFamily]

I am performing an audit on a few doctors and I am noticing that on their OP report and E/M they are not signing the actual note. It is still in UNREVIEWED status on the physical note. However within their internal system they state that the status of the file is SIGNED meaning they signed the note for that day somewhere but there is not a physical note that has the signature of the MD. So if the insurance requested the medical record it would not show a signature on file. Only a print screen of the system could be provided.

I am thinking that all of these would be unbillable since they are preliminaries even though their internal system says that they signed the note with a date stamp.

Any thoughts? I am meeting with the MDs and want to make sure that all of my ducks are in a row and these are truly unbillable or not.

Thanks!

 

[FTessaBartels]

Huh?

Are you saying they cannot print out a copy of the electronic note AFTER they have signed it?

Our notes are stored in an electronic system and "electronically" signed. They don't have an ink signature on them, but when you print them the statement "signed by Dr X on mm/dd/yy" is printed on the bottom. This is perfectly acceptable.

Hope that helps.

F Tessa Bartels, CPC, CEMC

 

[LewinFamily]

The problem is that when you print the electronic copy there is no signature or time/date stamp... So if submitted to insurance it shows UNREVIEWED above their name, instead of electronic signature and date/time stamp.