Wiki Signed consent form vs Informed consent in procedure note

[tlynn727]

I need to know if the procedure note has Informed Consent, but there is not a signed consent form in the EMR, is the Informed consent in the note sufficient for billing? Are both required? I need help with this please.

Thank you in advance for any advice.

 

[csperoni]

I'm not sure I understand your question. Sufficient for billing what? The procedure? It is good medical practice to have signed consent forms, but it is not a billing requirement.

 

[thomas7331]

Obtaining a consent from a patient is a legal requirement, not a billing requirement. As such, this is a question you should direct to your organization's compliance officer or legal counsel because they are the ones that should direct you on this. You need someone with an understanding of your local and state requirements as well as your organization's policy. If your provider is not appropriately obtaining or documenting consent, this is not going to be corrected by not billing for the service. I know this isn't much help, but I always advise against taking information about legal matters from the internet and/or anonymous sources whose credentials you don't know.