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Thread: Docmentation

  1. #1

    Default Documentation

    AAPC: Back to School
    I need to find something in writing as to the fact that all medical records that can be coded from need to be signed by the doctor. Where is that documented?
    Last edited by kdesimone; 01-21-2009 at 04:43 PM. Reason: Misspelling

  2. #2
    Join Date
    Apr 2007
    North Carolina


    B. Signature Requirements
    Medicare requires a legible identifier 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. (


    To ensure that medical record documentation is accurate, the following principles should be followed:

    The medical record should be complete and legible.

    The documentation of each patient encounter should include:
    o Reason for the encounter and relevant history, physical examination findings, and prior diagnostic test results.
    o Assessment, clinical impression, or diagnosis.
    o Medical plan of care.
    o Date and legible identity of the observer.
    If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred.

    Past and present diagnoses should be accessible to the treating and/or consulting physician.

    Appropriate health risk factors should be identified.

    The patient's progress, response to and changes in treatment, and
    revision of diagnosis should be documented.

    The Current Procedural Terminology (CPT) and International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record.


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