Ophthalmology and Optometry Coding Alert

Question: We’re having trouble making sure our providers meet signature requirements for their charts and labs. Can we include each physician’s name at the bottom of our chart and leave space for them to sign and date above their name? For labs or other correspondence that comes in, can each physician use a stamp of his printed name and credentials, then sign above where he stamps? I know we can’t use a signature stamp, but am not sure about these other options.

Michigan Subscriber

Answer: You may use a stamp with the printed name and credentials on the medical record, but the physician must actually sign above the stamped name to indicate his review of the report. It would also be wise to have a signature log with the physician name and credentials printed and next to that, a signature by the physician and initials by the physician. As you know, you cannot use a signature stamp for the actual physician signature. Medicare has information in their manuals on signature requirements.

For example, Dr. Darren Smith sometimes signs his charts as “Dr. D. Smith,” “D. Smith, M.D.,” “D.S.,” or “Darren Smith, M.D.” The signature log must include each of those signatures or initials so you can provide the information to auditors as needed.

Caveat: The only exception would be if the applicable regulation, NCD, LCD, or payer manual has specific signature requirements. In that case, the specified requirements would take precedence.