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Signature requirements for E/M (Non-CMS providers)

  1. Question Signature requirements for E/M (Non-CMS providers)
    Medical Coding Books
    I know CMS requires the physician signature for all billed suervices. Although it stands to reason that commercial carriers would have the same requirements. I have supplied them with CMS guidelines. As so many of you know, some physicians fear CERT & RAC audits and will do what they have to do for Medicare. They don't feel compelled to follow the same guidlines for commercial carriers, especially when it comes to E/M.

    Does someone have a resource for E/M guidlines regarding documentation and signature for commercial carriers? Management here and I would be very grateful for any guidance you may give in this matter.

    I look forward to seeing some of you in Jacksonville in a couple of weeks.

    Thank you,


  2. Default
    Are you talking about the physician signing the chart notes?? If that's the case then YES they have to sign any and all documentation. If they don't you can't bill for the services.

  3. Default
    We all know this to be true, but I need a source like the AMA or an entity like that. I work for some physicians, who believe they only have to be compliant when billing government programs. They require something other than our (coders) common sense opinion.

    Does anyone know of a source like that where I can show them in writting they have to take 2 seconds of their time to sign each medical record?

    Thank you,


  4. #4
    North Carolina
    There is a CPT Assistant dated June 1992...Topic... "Principles of Documentation"

    9.All entries to the medical record should be dated and authenticated.

  5. #5
    Casa Grande & Phoenix
    You can also go online for most Insurance Companies and look for provider manual and they usually mention providers agreement with compliance and charting. Whenever Dr's question guidelines regarding Insurances I check there and usually find what I am looking for as well as tools for staff to follow. Hope this helps.
    Tara Johnson, CPC

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