Physician signatures on office dictation

[Tivey]

HI~
I am wondering if someone can point me to some documentation regarding physicians needing to sign off on their transcribed office notes.
They are wanting to have the transcriptionist transcribe the note and put "dictated but not read" at the bottom. I have read that this will not hold up in an audit. Anyone have any addtional information?
Thank you!

 

[member7]

Signatures

Hi. For Medicare, check the Program Integrity Manual in chapter 3 under the CMS website. Otherwise, check with the carrier for your state for their signature requirements. Hope this helps.

 

[janetmoh]

I've never heard of such a thing. Of course they have to sign the dictated note!! How can they expect to get reimbursed for it without a signature??! When they sign they are "authenticating" the note. They are verifying that this care was given.

 

[kbreeden]

Hello,
My physicians don't sign the actual office dictation but do sign the speedbill for the visit that day. Should this be something we change?

 

[member7]

Signing the superbill is fine, but the notes that support that superbill should still be signed by the provider rendering the service because that is what is required. I find that when audit requests are made, most providers do not include their superbills. Most send in a copy of their 1500 forms.

 

[mcpalmeter]

Got to love it! Dictated but not read. That's like saying, I dictated this, but I could care less whether the information in this legal medical record is correct or not. The sign off is the physician's authentication of the note. If they want to minimize medical risk, they should review the transcribed note and verify that the information is accurate.


Maryann Palmeter, CPC

 

[bprater]

It is advisiele that the physician read the document and then sign off on it