Wiki Doctor completion of notes

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amccracken1108

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I can't seem to find anything online, unless I am looking in the wrong area...

Are there specific rules on how long a doctor (or healthcare provider) has to complete and sign off on their notes?

i have a provider I bill for who doesn't close and sign off on her documentation for about 3-4 weeks at a time. If anyone can point in a direction that I can show rules or policies about how long they have to sign off on a note that would be great.
 
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3.3.2.4 - Signature Requirements (Rev. 11032; Issued: 09-30-21; Effective: 10-12-21; Implementation: 11-10-21
Providers should not add late signatures to the medical record, (beyond the short delay that occurs during the transcription process) but instead should make use of the signature authentication process. The signature authentication process described below should also be used for illegible signatures.

Edited to add: Internal compliance departments and hospitals usually have policies and procedures about this. Some will withhold privileges and/or release of claims for repeated late signers you can look at your internal policies for your place of employment.
 
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I saw that - but that isnt giving me an exact amount of time the note has to be signed in, thats what I need to "prove" to the provider....
 
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I think there may be a MAC or 2 that gives an exact timeframe, but my understanding is that CMS states things like "timely" and "as soon as practicable."
For example, WPS states a reasonable timeframe is 24-48 hours.
I do think we can all agree that unless the provider was away or ill, 4 weeks is not "as soon as practicable."
 
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There's no guideline I have found yet that is so exact. A payer here or there may have something in their own policies but it's doubtful. Christine is correct above.

Another example is Novitas: https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00005015
2. What is an acceptable timeframe for signing medical documentation?
The regulations do not provide specific timeframes other than to say 'short/brief delay'.

Just some extra info with good points:
Outdated but still valid ideas
https://www.aafp.org/journals/fpm/blogs/gettingpaid/entry/here_s_your_sign.html
~One final note from the CMS guidance: If reviewers identify a pattern of missing or illegible signatures, it will be referred to the appropriate program integrity contractor for further development.

Sure, you can do a signature log and attestations but why go through all that when you can just sign the note at the time it's done? Take backs can happen because of insufficient documentation errors identified by audits. Looking to internal policies and procedures has helped me in this situation. I also ask the provider why they would want to put themselves at risk by not signing in a timely manner. Technically nothing should be billed out without being signed either as it is not considered "complete". I know it's frustrating and the records pile up. I know they are treating hundreds of patients. It's also just good patient care though, what if that note has to go to another provider or the patient requests a copy of their records, etc? Not to mention the legal implications when it comes to med records.
 
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