Signature Requirements

melissa.reed22

Contributor
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Moscow Mills, MO
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I have a doctor who requests that I code his surgeries from preliminary op reports before he signs them. He says he never changes anything on any notes he signs because he doesn't even look at them. He just signs them because there are so many. I am looking for documentation that states I cannot code from a note that he has not signed and finalized, but I can't seem to find anything that says that. Can someone please help me? Thanks!
 

Chelle-Lynn

True Blue
Local Chapter Officer
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Modesto, CA
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Not sure if this is what you are looking for...but the following Medicare guidelines references signature requirements. MedLearn Matters article 6698.



To maintain compliance, providers must be diligent and implement measures to ensure that they are in compliance with the new signature guidelines so that they have sufficient documentation to support the services provided and to avoid potential requests for refunds if a contractor is unable to validate the provider signature on a record. To keep their dollars and avoid unnecessary inquiries, providers should implement an active validation process

Providers should not add late signatures to the medical record beyond the short delay that occurs during the transcription process. Generally 24–72 hours is the typical turnaround time for the provider transcription process.
 

jepcpc

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Tampa
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MLN Article

There is an article on the CMS website. AAPC site wont let me upload the pdf because it is too large. The title is "Complying with Medicare Signature Requirements" The article footer shows ICN 905364 October 2013.

It states Medicare cannot accept a back dated signature. My company will not allow us to code surgical reports until finalized (i.e., electronic signature recorded)
 
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