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Thread: unsigned medical records submission

  1. #1

    Default unsigned medical records submission

    AAPC: Back to School
    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
    Join Date
    Apr 2007
    Louisville, KY


    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.
    Kevin B. Shields, RHIT, CPCO, CCS, CPC, COC, CCS-P, CPC-P, CPC-I

  3. #3
    Join Date
    Apr 2007
    White Plains, NY


    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.


  4. #4


    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.


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