Practice Management Alert

Question: My office’s electronic health record (EHR) system was down for a few hours during a storm. A provider started a note for a patient but couldn’t finish it with the system being down. I’m looking over the documentation now and trying to code the encounter, but the provider never signed it. Does it require a signature?

AAPC Forum Participant

Answer: Signatures are a crucial part of a patient’s medical record, and while most payers require a signature, there are situations where the timing may be adjusted, as long as there’s documentation to explain why. The Centers for Medicare & Medicaid Services (CMS) requires a provider signature to authenticate the services provided or ordered, explains

Medicare Administrative Contractor (MAC) Palmetto GBA. Although individual payers may have different rules, many follow the standards put forth by CMS.

“The purpose of a rendering/treating/ordering practitioner’s signature in patients’ medical records, operative reports, orders, test findings, etc., is to demonstrate that services submitted to Medicare have been accurately and fully documented, reviewed and authenticated. Furthermore, it confirms the provider has certified the medical necessity and reasonableness for the service(s) submitted to the Medicare program for payment consideration,” Palmetto GBA says.