Wiki Signature on chart note


Los Osos, California
Best answers
I am trying to find something that supports what a "complete" document is and the need of a signature prior to billing. In the office, we are in disagreement on sending claims electronically to insurance companies. I say you need the provider to sign off on the report before billing. A co worker feels it can be sent if the signature is pending and is sending the claims without the signature. We have EMR and the note is electronically signed with the date and time. If the claim is audited, they will see the day the claim was received and due to the date and time stamp, they will know it was billed prior to the signature. Report is not complete if the provider did not sign off on the report. I am not able to find anything that is helpfull with it being a incomplete report. Does anyone out in the auditing / coding wold have something? I need hard facts to support this issue.
Thank you!! :)
This falls more into compliance than coding. So, TECHNICALLY, Medicare will accept a record that is not signed if the provider sends an attestation statement. This does NOT apply to orders. It is certainly not recommended, would not be best practice, and absolutely should not be done on a regular basis. In my current computer system, you cannot even finalize/submit the claim without an override and explanation until the note is signed.
I do not submit claims with unsigned records and instruct my staff to do the same.
My take - how do I know the note is even finalized until the clinician signs?? Maybe a dictation has incorrect info. Or the provider needs to add a diagnosis, or that they spoke to another clinician about the patient.
It's a pretty risky and terrible idea to file claims pre-signature and pre-finalization. Are you going to get attestations every single time? It's one of the biggest red flags.
I agree with Christine, how would a coder know the record was complete and correct if the provider has not validated it and signed that it is?
Large healthcare systems and most practices, even small ones, should have a policy and procedure about this. It is a compliance issue. You, as staff coders/billers should not be independently making or debating this decision without an established policy from the higher level of the practice, manager, administrator, etc. If there is no company or practice policy about it, that's scary. I have seen hospitals suspend providers for unauthenticated records/missing signatures where they don't sign their charts for months.

Examples: - Signature Requirements

"Failure to submit medical records with a valid signature is one of the top reasons for claim denials and payment delays, nation-wide. This is also one of the most easily preventable denial reasons. All health care providers should be aware of the increased level of scrutiny regarding signatures in medical records and take steps to ensure they have procedures in place to address this critical issue."

"The top reason services are denied, upon medical review, is invalid signature, and no attestation was provided upon request. Failure to submit records with valid signatures upon request, or valid and timely attestations, will result in your claims being denied."