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documentation signatures

  1. #1
    Default documentation signatures
    Medical Coding Books
    Can anyone point me in the direction of cms rules on dr signing documentaion, ie history's and/or dr dictation? Thanks alot Lauren

  2. #2
    Post CMS Manual
    CMS Program Integrity Manual (PUB.100-08), Chapter 3, Section - Documentation Specifications for Areas Selected for Prepayment or Postpayment MR, B. Signature Reuirements, reads "Medicare requires a legible identifier for services provided/ordered. The method used (e.g. handwritten, electronic, or signature stamp) to sign an order or other medical record documentation for medical review purposes in determining coverage is not a relevant factor. Rather, an indication of a signature in some form needs to be present."

    There is more in that section - i.e., advsing that Providers should recognize that using alternative methods opens a potential for use/abuse.

    I have seen services denied after payment when the hospital provided records to a government review agency, and the services were not properly documented/signed. Physicians and other providers need to realize the importance of their documentation and signatures. Hope this helps.

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