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danilyn

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Hello!

We are having a debate in the office about preliminary operative reports vs electronically signed reports.

It is debated you can code and submit a claim based off a preliminary report. Some feel per Medicare guidelines the report MUST be authenticated/electronically signed off on before a report is coded and a claim is filed.

Does anyone have any type of supporting documentation about this issue? I would really appreciate it. Thank you!!!:)
 
Medicare does state that documentation must be signed in order to be acceptable. I recently had a request for redetermination denied by them because without noticing it, I sent as documentation an office note that had not been electronically signed yet. Medicare actually stated in their decision letter that had the office notes been signed, they would have reprocessed the charge for payment. Fortunately, there is another level of appeal. I say all that to say that what that person said about Medicare is true. So really, it's not good to code from preliminary reports, which is basically what an unsigned report is. The doctor could very well go back to sign the report and change something that affects the coding unbeknown to the coder. I guess it would depend upon how your documentation system is set up, but until the doctor has finalized and signed the report, it really shouldn't be coded.
 
danilyn said:
Hello!

We are having a debate in the office about preliminary operative reports vs electronically signed reports.

It is debated you can code and submit a claim based off a preliminary report. Some feel per Medicare guidelines the report MUST be authenticated/electronically signed off on before a report is coded and a claim is filed.

Does anyone have any type of supporting documentation about this issue? I would really appreciate it. Thank you!!!:)
Click to expand...

CMS Documentation Guidelines has a section called "General Principles of Medical Record Documentation", which is applicable to all types of professional services...
Item #1 says, "The medical record should be complete and legible."
Item #2 says, "The documentation for each encounter should include...date and legible identity of the observer [in other words, the author]"
Item #7: "The CPT and ICD-9-CM codes reported on the health insurance claim form or billing statement should be supported by documentation in the medical record."
The physician's signature on the claim is attesting that all services reported are supported by medical record documentation, which has been verified as complete and accurate. I would say that taking those things into consideration, the operative report should be complete and signed, at least before claim submission.

It's usually better to go off of a final report anyways - by then, any pathology reports, or final thoughts from the physician regarding the patient's diagnosis/condition/outcome of the procedure, should be available for you to select more accurate and specific codes, which is usually beneficial to getting the claim paid on the first submission anyways. If they're in a hurry to get paid, then they should complete their documentation in a timely manner. You could code off of the preliminary report, but I would strongly advise holding the claim until you're able to verify the code selection, when the final report is complete, to avoid any compliance risks.

So, in a nutshell, my logic on the issue looks like this:
Not Documented = Not Done (No claim can be submitted for services not documented)
Not Signed = Not Documented (Completely)
So, by association: Not Signed = Not Done = No claim

Hope that helps! ;)
http://www.cms.gov/MLNMattersArticles/downloads/MM6698.pdf
 
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