Hi - I'm trying to find some clear documentation regarding requirements on when notes need to be signed. We have one primary care provider whose notes are billed before they're signed (he completes them, but doesn't sign them very quickly), and I'm trying to find clear guidelines to indicate that they need to be signed prior to billing. In looking for these, I'm also finding reference to some carriers having requirements as to how long a provider has to complete and sign their note, but again, I'm having a hard time finding specifics on this. I know CMS states "You may not add late signatures to orders or medical records (beyond the short delay that occurs during the transcription process)" but this is frustratingly vague. Our MAC is National Government Services and I can't find anything more specific on their website, either.
I really want to get our office into compliance on this, but it's hard to get these changes implemented without very clear documentation to back up my claims of non-compliance, and I'm really hoping to avoid contacting our payers directly. The CMS guideline I mentioned above might help me make headway, but I suspect it will just get me a request for "further information" - so I'm hoping to already have that info in order to avoid any debates (not my strong point). Can anyone help me?
I really want to get our office into compliance on this, but it's hard to get these changes implemented without very clear documentation to back up my claims of non-compliance, and I'm really hoping to avoid contacting our payers directly. The CMS guideline I mentioned above might help me make headway, but I suspect it will just get me a request for "further information" - so I'm hoping to already have that info in order to avoid any debates (not my strong point). Can anyone help me?