Question Note signature timeframe requirements

ca_cpc

Networker
Messages
35
Best answers
0
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?
 

AmandaBriggs

Expert
Messages
305
Location
Coeur d'Alene, Idaho
Best answers
1
Some state Medicaid agencies have what's known as a "72 hour rule" meaning that the note has to be signed within 72 hours of providing the service. I would check to see if your state Medicaid agency has adopted this rule. Otherwise, there is no other language that I'm aware of other than the vague statement by CMS that you quoted above.
 
Last edited:

csperoni

True Blue
Messages
1,542
Location
Selden
Best answers
3
To my knowledge, by CMS it is just the vague statement about signing timely and they leave it to the MAC if they wish to define it further.
I would just note this - you state "he completes them, but doesn't sign them very quickly." If it's not signed, it is not complete. You should not be billing for anything that is not already signed.
CMS does specify it needs to be complete and signed prior to billing.
 

ca_cpc

Networker
Messages
35
Best answers
0
1 - I hadn't checked Medicaid! Looks like mine doesn't have the 72-hour rule, but it's good to know others do and ours could decide to go with it at any time.
2 - csperoni, Can you point me toward that specific guidance? That's actually what I had been looking for initially and couldn't find, but I wanted to look into the timeliness factor as well anyway and thought it would solve the problem regardless. All I found from CMS was guidance in case of unsigned notes found in an audit - which I know implies they need to be signed before billing, but I really need more than implications to make my case. I very much want to be in compliance, but making these changes isn't always easy when people are used to doing it a different way.
 

csperoni

True Blue
Messages
1,542
Location
Selden
Best answers
3
2 - csperoni, Can you point me toward that specific guidance? That's actually what I had been looking for initially and couldn't find, but I wanted to look into the timeliness factor as well anyway and thought it would solve the problem regardless. All I found from CMS was guidance in case of unsigned notes found in an audit - which I know implies they need to be signed before billing, but I really need more than implications to make my case. I very much want to be in compliance, but making these changes isn't always easy when people are used to doing it a different way.
From Noridian:
Note: "Medical records should be complete....." If it's not signed, it is clearly not complete.
 
Top