Wiki Is this fraud?

[jgossett]

One of the ophthalmologists I code for has his op tech put his initials on almost all of his notes. She stands in the exam room with the doc and completes the note as the doctor completes his exam of the patient. Then she adds his initials next to hers at the bottom of the note. Something about this seems wrong to me and I would value any opinions/advice.

 

[thomas7331]

I would not call this fraud, however it is not compliant with the signature requirements for documentation. It sounds like your tech is acting as a scribe without identifying this in the record. In addition, providers must authenticate the documentation themselves with a valid signature. In the absence of such, your practice could face problems and potential negative financial impacts if audited.

Here is a good reference document from CMS about the Medicare signature requirements, and it includes a number of links that will direct you to additional information:
https://www.cms.gov/Outreach-and-Ed...gnature_Requirements_Fact_Sheet_ICN905364.pdf

 

[jgossett]

Thanks, Thomas