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Signatures for Claims

  1. #1
    Greenville, SC
    Default Signatures for Claims
    Medical Coding Books
    Is there a specific requirement by CMS that states the documentation must be signed by the billing provider prior to the claim being submitted?

  2. #2
    Default Not that I am aware of...
    I have yet to locate anything that says this. They want to records complete ASAP, which would include a signature but I find it very interesting the instructions given to RAC.

    2. Minor Omissions
    Consistent with Section 937 of the MMA, the RAC shall not make denials on minor omissions such as missing dates or signatures.

    As far as I know there is no time limit to when they can sign a record either. Do I feel comfortable when providers are signing year old records? No, I don't but they can. Or at least they can per our attorneys.

    Laura, CPC, CEMC

  3. #3
    North Carolina
    My carrier......

    Documentation Pointers

    -Medicare expects the documentation to be generated during the time of service or shortly thereafter.
    -Delayed entries within a reasonable time frame (24-48 hrs.) are acceptable for purposes of clarification, error correction, the addition of information not initially available, and if certain unusual circumstances prevented the generation of the note at the time of service.
    -The medical record cannot be altered. Errors must be legibly corrected so that the reviewer can draw an inference as to their origin. These corrections or additions must be dated, preferably timed, and legibly signed or initialed.
    -Every note stands alone, i.e., the performed services must be documented at the outset.
    -Delayed written explanations will be considered for purposes of clarification only. They cannot be used to add and authenticate services billed and not documented at the time of service or to retrospectively substantiate medical necessity. For that, the medical record must stand on its own with the original entry corroborating that the service was rendered and was medically necessary.
    -All entries must be legible to another reader to a degree that a meaningful review can be conducted.
    -All notes should be dated, preferably timed, and signed by the author.
    -In the office setting, initials are acceptable as long as they clearly identify the author.
    -If the signature is not legible and does not identify the author, a printed version should be also recorded.


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