Wiki Timely Completion and Signing of Medical Records

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PLDalsoren

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Our billing office is having an issue with unsigned medical records being sent over to us for billing. We have communicated with the providers on a number of occasions that they need to sign the patient note before sending for billing. I have looked online to see if there is any guidance from CMS on what is considered an acceptable time frame for signing medical records. There doesn't seem to be a definite time frame. I'm curious to know what policy other practices have in place or if anyone knows of specific guidance from payers on this? I know this can potentially be a compliance issue and a problem if they were to be audited. Thank you for any advice you can provide!
 
This question is asked frequently here on the forum. As you've said, CMS doesn't give a definite time-frame requirement for completion of medical beyond stating that provider "can’t add late signatures to orders or medical records (beyond the short delay that happens during the transcription process)." This is something that a coder can't do a lot about other than giving feedback and education to the providers, which may or may not be effective. The management team of the organization that employs the providers are really the ones who need to take action to set a policy and hold the providers accountable to it. Some large organizations will suspend providers or revoke their facility privileges if they consistently fail to complete their records in a timely manner according to the organization's policy. Not only is it a compliance risk but it can also cause a loss of revenue. If the organization where you work doesn't have such a policy, I would certainly refer the matter to your management or compliance department and make sure they're aware of the problem. In the absence of a policy, I'm not sure there's much more that an employed coder can do.
 
CMS itself just gives a vague statement - I think as soon as practicable or something like that. Some MACs have issued more specific timeframes as a guideline. Maybe FSCO stated 24-48 hours?? But yes, as @thomas7331 states, it is best if the employer has an official policy. For me, I specifically do have a provider who is always behind on signing - office notes, op notes, everything. The hospitals have a policy of signed within 48 hours and start sending notifications. If it goes beyond a certain timeframe, they will threatened suspension of privileges and carry through if needed. Within the practice, we advise that if it goes beyond 7 days (which I actually think is longer than it should be), it is officially delinquent. But we have no authority to carry out any action when it is delinquent other than notifications. It is a huge thorn in my side.

PS - My coders are instructed they may not bill out until documentation is signed. That is a corporate requirement, but something I would require for my team even if it were not.
 
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Agree with all the advice above. In my experience, the provider was fined monetarily due to loss of revenue in a private practice, compliance risks and the facility privileges were revoked if it was a very large number of charts and/or super late missing signatures.
As Amanda mentioned, some states have regulations and some payers may also have separate ones.
 
It is our group policy that claims are not billed until services are documented and signed due to the liability. We have one doc who used to sign services late. When we sent signature reminders to that doc, we included the fee for each service so that they could see how much $ was pending. Depending on your doc, that might be a motivator.
 
camillecoder@hotmail.com said:
It is our group policy that claims are not billed until services are documented and signed due to the liability. We have one doc who used to sign services late. When we sent signature reminders to that doc, we included the fee for each service so that they could see how much $ was pending. Depending on your doc, that might be a motivator.
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Agree, we had a weekly list that went to all providers showing the oustanding charges on hold for signature.
 
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