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Thread: Legality of coding unsigned op notes??

  1. #1
    Join Date
    Apr 2007

    Question Legality of coding unsigned op notes??

    AAPC: Back to School
    I work for an ASC and this is an on-going discussion.
    Is it legal, or more precisely, can we be held liable in a lawsuit if we code and bill an unsigned operative report?
    If anyone has the answer do you have a website or document I can reference?

    Thanks in advance for any input!

  2. #2
    Join Date
    Apr 2007


    I also would like to know the answer to that ...I code from unsigned Operative Report as well even though the Doc signed it after...feedback please!!!

  3. #3
    Join Date
    Apr 2007

    Smile Signature not required

    We got an answer from one of our consultants.
    While it would be a plus to have the op notes signed it is not required from a legal standpoint.

  4. #4
    Join Date
    Apr 2007


    What happens if it never gets signed? I personally will not release anything that is not signed. What if the dictation is wrong or missing something? I would like to see something in writing not just a consultants verbal opinion.

    Effective September 3, 2007 CMS Publication 100-8 (Program Integrity Manual), Chapter was revised to state, in pertinent part, the following guidance:
    Medicare requires a legible identity for services provided/ordered. The method used shall be hand written or an electronic signature (stamp signatures are not acceptable) to sign an order or other medical record documentation for medical review purposes.

    The only change made here was signature stamps are no longer acceptable, they have always required a verification of services provided.

    Laura, CPC

  5. #5

    Default Unsigned OP Reports

    So my question do the OP Report have to besigned prior to us sending out the surgry charges to Medicare? I have a Doctor who thinks that we can bill the carriers, and he not sign the OP Reports until later. I really nned help on this.

  6. #6

    Default Unsigned Surgery

    The saying that if it isn't documented it didn't occur apply. Valid documentation is signed, dated and timed by the author. If this is not signed there is no valid documentation.

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