Neurosurgery Coding Alert

Question: Is a physician required to sign and date dictation (office notes) if a transcriber has already typed the physicians name and date? Will payers accept unsigned  documentation?

Kansas Subscriber

 
Answer: Neither CMS nor individual payer local medical review policies specify that office notes must be typed, only that documentation be legible. If the office notes are transcribed (whether typed or rewritten) pursuant to the physicians dictation, he or she should review the documentation, correct any mistakes and sign and date the final copy. Although time-consuming, this is in the physicians best interest. Remember, the physician not the typist or transcriber is ultimately responsible for the accuracy of the medical record, and the payer and auditors will hold the physician responsible for misleading or incorrect documentation that leads to improper reimbursement. Authenticating the documentation reduces your chances of running afoul of any mistakes, and may in some cases improve patient care.