unsigned visit notes

trarut

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We recently had a provider leave our practice and I'm auditing the unfinished charting report from our EMR - since apparently it didn't occur to anyone to have her make sure all of her documentation was complete before her last day :confused: I'm finding a handful of unsigned visit notes for several of our providers and I'm wondering how the rest of you handle unsigned visit notes that are more than let's say 30 days old. Do you do a separate provider attestation for the service date?

My other question is how do you handle unsigned notes for a provider who is no longer with the practice? The provider is a nurse practitioner and the services were performed incident-to. Ordinarily I would say that the NP must sign as the rendering provider but the incident-to piece has me questioning that. Is it acceptable to have a statement added to the note indicating the NP is no longer employed with the practice and unable to sign the note then have the supervising MD sign? Leaning toward "no" but curious what anyone else may have to say on the matter...

Looking forward to your responses!
Tracy
 

csperoni

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This to me is pretty tricky. My employer does not permit submitting any bills unless the notes are signed by the provider. In fact, if the note is not signed, the system is built that you cannot override this and cannot submit billing charges.
I know some commercial carriers have guidance that does specify in your contract that the note must be signed prior to billing. Many people infer that CMS has this same guideline, but I've never seen it from CMS directly in black and white. It says complete, and to me it's not complete if not signed, but they don't say signed. Some MACs further specify beyond CMS' very vague guidance.
In my practice, once an office note hits 30 days unsigned, we post a no charge fake CPT just to close it out in our billing system. We do not bill for it and the provider does not get credit for it. We do remind the providers once it's more than 2 weeks. The EHR system will allow the provider to sign at any time, but once we've posted the no charge, we don't even get a prompt when/if it is signed and it does not get billed.

Unsigned notes for a provider no longer with the practice. Well, you can't even do an attestation. No one else may attest other than the person who actually performed the service. And the note may not only be unsigned, but not have completed documentation. IF the visit met all incident-to requirements (established pt, established plan of care, physician onsite, etc), I advise to check your MAC for guidance. I thought the answer would be no, but found this from Noridian https://med.noridianmedicare.com/web/jfb/cert-reviews/signature-requirement-q-a :
Q18. When a Physician's Assistant (PA) is billing under his/her own number, should he/she sign the chart notes or should the supervising physician sign them?
A18. The documentation should be signed by the provider providing the service and billing for it. In an" incident to" scenario, the documentation should be signed by the supervising provider with a reference in the notes as to who performed the service or co-signed.
So, if you have an NP note that is complete except unsigned AND met all incident-to requirements, it appears the physician may sign & reference the NP who performed the service. That would be billable per Noridian under the physician.

Summary: check your local MAC and check with your commercial carriers. If it was a handful of notes, I honestly would probably not even bother checking. Have the supervising provider sign to complete with a note that the NP is no longer working for you. Don't bill to insurance unless you know the carrier is OK with that process.
 

trarut

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Thanks, Christine. Unfortunately, our MAC is CGS and they're not very forthcoming with guidance. Your post is pretty much what has been going through my mind and I appreciate you taking the time to reply. I'll do some more digging to see what I can find.
 
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