# Signature vs. Initials



## kathymoon (Feb 12, 2010)

I need some help. We were auditied by MedAssurant and they stated that one of our docs is not meeting the signature guidelines.  They sent back a copy of a consultation by another physician (for our patient) stating that his initials were not enough on this record.  Are we not correct that initials are enough when he is simply stating that he has reviewed the specialist's letter or consultation notes (hospital)?  And they are filed in the patient's chart.  I appreciate any help.


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## LLovett (Feb 12, 2010)

I have never heard of a signature requirement for consult letters received back. This is news to me. Could they supply you documentation regarding this?

Laura, CPC, CPMA, CEMC


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## myeo (Feb 19, 2010)

I agree with Laura.  I have not heard of this either.  I would definetly challenge this.


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## eadun2000 (Feb 20, 2010)

unfortunately on HCC auditing you audit the "whole" patient record.  If a consultation from another physician is in "your" chart, you are audited on that.  I never ever thought that was fair.  It should be what your physician did, not another.  What control do you have on another physician?  I think it is ignorant!


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## TTcpc (Feb 22, 2010)

When we were audited the only thing that we were informed that was required was initials and a date to show that the physician reviewed the letter/note prior to it being filed in the patient's chart.  Most physicians that I have worked with have only initialed and dated to show that he/she had seen the record and it's never been a problem.   
I would ask them for documentation on a full signature being required.


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## sgoodknight (Feb 26, 2010)

Although I cannot produce any Medicare guidelines, I have read numerous articles stating that the minimal signature is first initial, last name and credentials (e.g. J. Doe, M.D.) even when reviewing results.

It sounds as if this carrier was applying those guidelines to anything that was reviewed.

I've been cautioning my doctors on this for months.  Thanks for your post.  Do you mind sharing with me what state you are in?

Thank you,

Sandy Goodknight, CPC, CPMA, CEMC
Indiana


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## kbarbag (Feb 27, 2010)

Current CMS guidelines require a Legible signature. Highmark recently did audits on Consults and denials ran wild on documentation that did not have a legible signature. This denial is not appeallable. 
Kathy Barbagallo, CPC
NJ


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## FTessaBartels (Mar 3, 2010)

*Huh?*

You are saying that Medassurant is giving you a deficiency for Doctor A - who requested a consultation from Doctor B regarding Doctor A's patient - because Doctor A did not sign and date the report he received back from Doctor B?

How is this a deficiency?  Doctor A isn't billing for the consultation.  Doctor B is billing.  

We file all sorts of records from other physicians/hospitals in our patients files - it is part of the patient history. None of our doctors sign (or even initial) any of these documents.

Wow. I'm speechless.

F Tessa Bartels, CPC, CEMC


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