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Does anyone know if patient charts need to be countersigned by a physician? I just want to be sure that we are following current statutes or regulations. I am located in California. Thank you!
Are they performing under incident to? I am not in your jurisdiction, but my physicians co-sign incident to documentation. They do not on regular office visits.
Q1.What type of documentation is required to prove that the supervising physician was physically present in the office suite?
A1. For ancillary staff, the supervising physician/non-physician practitioner (NPP) may sign the medical record or a record may be kept elsewhere in the office. Neither Noridian nor Medicare has prescribed how this must be documented, but the office must have documentation to support the presence of the supervising provider if the record is audited. For services performed by NPPs, the medical record may be signed by the NPP or the supervising (billing) physician; however, it is recommended that the supervising physician co-sign the progress notes as the physician's signature lends credence to the "incident to" requirements having been met, as well as the fact that the physician supervised the work.
Q18. When a physician's assistant (PA) is billing under his/her own number, should he/she sign the chart notes or should the supervising physician sign them?
A18. The documentation should be signed by the provider providing the service and billing for it. In an" incident to" scenario, the documentation should be signed by the supervising provider with a reference in the notes as to who performed the service or co-signed.