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unsigned medical records submission

  1. Default unsigned medical records submission
    Medical Coding Books
    I need to know the law for submission of medical records for in and out of NYS. Handwritten records but some not signed. What recourses do I have for payment and nonpayment of claims?

  2. #2
    Location
    Louisville, KY
    Posts
    1,101
    Default
    I'd have to further research the "laws" associated with medical record completion. However, Joint Commission and Medicare Conditions of Participation require authentication of records, including the identity of the author. These standards should be employed to "encourage" providers to sign their notes in a timely fashion.

    Hope this helps.

  3. #3
    Location
    White Plains, NY
    Posts
    123
    Default
    I am a payer in NYS. If we do an audit and the record is unsigned, we won't accept it as documentation that the service was done.

    Lin
    CFE, CPC, CPMA

  4. #4
    Default
    I perform internal audits in Ky. and I fail an audit if it is not signed, but I educate my providers about the guidelines and requirements regarding handwriten and electronic signatures . I have also had providers attach an Attestation Sheet to the unsigned progress note. I educate my providers this is an error that does result in money reimbursement/recoupment by any insurance company.

    KSS
    CPC

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