Wiki Unsigned medical record and billing

[broundy]

Does anyone know if it is legal to bill an office visit without the documentation being complete including the physcian's signature? If this does in fact need to be done before billing, does anyone know where I can find documentation stating this.


Thanks

 

[bran1120]

Try CMS's website or your local Medicare carrier's website.

 

[bonnyr]

To quote from every seminar, webinar and billing manual, "If it's not documented, it wasn't done". Besided, how do you know what to bill until the notes are complete? If they are not signed, then how do you know they are complete and the provider is not planning to add more information? This is a very risky and potentially money losing practice.

 

[mitchellde]

To quote from every seminar, webinar and billing manual, "If it's not documented, it wasn't done". Besided, how do you know what to bill until the notes are complete? If they are not signed, then how do you know they are complete and the provider is not planning to add more information? This is a very risky and potentially money losing practice.

Well said! I preach this at every class I teach!