Wiki Signing of medical records

[Emmalia]

Hi, Does anyone know where I can find in writing how long a provider has to sign off on their documentation (ie; 24-48-36 hours) before Medicare considers it a "late signature"?

Thanks!

 

[slgarland]

I have the same question, getting the physician to sign his or her notes in a timely fashion is a constant problem in this practice

 

[mlbaker1974]

Per CMS here is your answer:

Question:

What should I do if I haven’t signed an order or medical record?

Answer:

You may not add late signatures to medical records (beyond the short delay that occurs during the transcription process).
Medicare does not accept retroactive orders. If the practitioner’s signature is missing from the medical record, submit an attestation statement from the author of the medical record.
Your contractor may offer specific guidance regarding addenda to medical records. If the order is unsigned, you may submit progress notes showing intent to order the tests. The progress notes must specify what tests you ordered. A note stating
“Ordering Lab” is not sufficient. If the orders and the progress notes are unsigned, your facility or practice will be assessed
an error, which may involve recoupment of an overpayment.

Reference: CMS “Medicare Program Integrity Manual” (Pub. 100-08), Chapter 3, Section 3.3.2.4.