I'm needing information on the signature requirements for medical records of other providers placed in our medical charts. Not necessarily "billing" requirments but overall medical records guides. Things not ordered by or performed by our physicians.
Currently, our physicians (family practice) sign everything that's placed in the medical chart. I think they only have to sign their own records and results of testing they ordered, but I can't find any specific rule or guideline mentioning this at all. Everything I've come across is from CMS and relates to signature requirments on orders and test results being billed.
I realize if the record from another physician is used for the MDM of one of our visits, the record should be signed and dated as it would be part of the documentation to support the level of service used. But, we receive many records from multiple specialists that would not be used for the majority of acute visits performed.
I'm trying to save our physicians a lot of time spent signing records unnecessarily.
Currently, our physicians (family practice) sign everything that's placed in the medical chart. I think they only have to sign their own records and results of testing they ordered, but I can't find any specific rule or guideline mentioning this at all. Everything I've come across is from CMS and relates to signature requirments on orders and test results being billed.
I realize if the record from another physician is used for the MDM of one of our visits, the record should be signed and dated as it would be part of the documentation to support the level of service used. But, we receive many records from multiple specialists that would not be used for the majority of acute visits performed.
I'm trying to save our physicians a lot of time spent signing records unnecessarily.