Urology Coding Alert

These two things are simple, but have a powerful effect on success.

Documentation that gives your providers the best chance of optimal reimbursement has several key characteristics: reliability, precision, completeness, consistency, and clarity. As our experts share, taking even simple steps, such as double-checking signatures and verifying basic details about the patient, helps ensure that claims meet those criteria.

Get a Signature – Every Time

Payers won’t consider documentation to be valid — no matter how detailed it might be — if it does not include a signature or other authentication. “Regardless of who writes the medical record entry, the record must be authenticated by the provider,” says coder Ann Bina in Charlotte, N.C.

Here’s why: Medicare requires that services provided or ordered be authenticated by the author with either a handwritten or electronic signature. Stamped signatures are permitted in some situations, such as when the author has a physical disability that prevents them from signing the record.

Unsigned documentation or a lack of attestation will result in a claim denial, Bina says, which could cost your practice thousands in forfeited reimbursement.

Back-up plan: Provider signatures might not always be legible to the average reviewer (such as an auditor). To help prevent issues, your office can create and submit additional documentation to prove that the signature does belong to the provider in question. Practices often do this through submitting a signature log that lists the printed name of the author/provider, the provider’s credentials, and the provider’s initials and signature.

“A signature log is a typed listing of physicians and NPPs identifying their names with a corresponding handwritten signature,” CMS says in its document, “Complying with Medicare Signature Requirements.” It continues, “This may be an individual log or a group log. A signature log may be used to establish signature identity as needed throughout the medical record. CMS encourages but does not require physicians and NPPs to list their credentials in the log.”

Conduct a Reality Check

Patients’ medical records follow them — forever. The use of technology-based record keeping makes it easier than ever for multiple clinicians to access information.

What it means: Providers should always double-check charts to ensure accuracy so that misinformation doesn’t become part of the record. While you might not know as a coder whether specific details are correct, you can read charts to verify that information doesn’t mistakenly carry over electronically from a previous visit’s note.