Wiki OP Notes: Is Rendering Physician Required to be listed on notes??

[ewilliams941@gmail.com]

Currently I am reviewing Operative Notes that have the Patient Name, Date of Procedure, Referring Physician, and the Description of the Procedure but NO RENDERING PHYSICIAN in the header. Though my personal knowledge tells me who the rending is, I believe their name should appear on the OP notes.

My question is simple: In the event of an audit, is it absolutely necessary that the rendering physician's name be listed in the OP notes?


I appreciate opinions and knowledge from everyone. Though if available, could anyone list a specific source dictating a clear yes or no answer. Unfortunately I could not find any helpful direction from other websites.

 

[mitchellde]

You need to try a web search for the federal register on this topic. It is hard to search the federal register and the links are hard to save once you get there. However the info you seek is there. Yes the operative note must contain the name of the surgeon that performed the procedure, and it must be signed by the surgeon.

 

[ValerieBatesHoffCPCCPMA]

No VALID provider signature?

This is what I was taught in the process of studying for my CPMA exam.

Medical Record Signatures

Any form of medical documentation produced within a medical practice should be signed by the author. Regardless of the type of provider or service performed (eg, a nurse visit or an MD providing a quick wound check), the encounter must be documented and signed.

According to CMS, “all medical record entries should be signed and dated, usually within 48–72 hours of the encounter but certainly before the claim for services is filed.” Records, orders, and reports not signed are considered invalid and may lead to a recoupment of reimbursement.

What is required for a valid signature?
For a signature to be valid, the following criteria must be met:
• Services that are provided or ordered must be authenticated by the
ordering practitioner;
• Signatures are handwritten, electronic, or stamped (stamped
signatures are only permitted in the case of an author with a
physical disability who can provide proof to a CMS contractor of an
inability to sign due to a disability); and
• Signatures are legible.
Reference: CMS “Medicare Program Integrity Manual” (Publication
[Pub.] 100-08), Chapter 3, Section 3.3.2.4 at http://www.cms.gov/
Regulations-and-Guidance/Guidance/Manuals/Downloads/pim83c03.
pdf on the CMS website.

https://www.cms.gov/Outreach-and-Ed...gnature_Requirements_Fact_Sheet_ICN905364.pdf

Medicare requires that services provided/ordered be authenticated by the author. The
method used should be a handwritten or electronic signature. Under certain circumstances,
a rubber stamped signature is acceptable. If you do not have an acceptable signature on
services provided/ordered, your Medicare payment may be impacted.

https://www.cms.gov/Outreach-and-Ed...k-MLN/MLNMattersArticles/downloads/SE1419.pdf