Wiki Signature Compliance

Create Wiki
A

AB87

Guru
Messages
214
Location
Jacksonville, FL
Best answers
0
If claims go out (E&M Visits and Surgeries) without Signature, Can the Coder be at Fault? or is it the Doctor? Just want some insight and hear Different point of views.

Thank You
 
There is no real straight answer to this. It falls more on intent and knowledge of what you are submitting.

Regardless of a signature if you as a coder, who holds professional knowledge of coding, documentation, and billing rules knowingly submits non-compliant charges you can be held accountable. Providers like to think they can "protect" you or take blame because as your superior they "told' you to do it and that is simply not so. The laws and penalites that exist apply to not just the provider but any person who knowingly breaks those laws.

I wouldn't run out and quit your job etc but if there is a situation I would document to whom and when education and corrective action was provided to as well as their response to it.

If you have management that you can report to I would also advise them as to what the situation is along with a copy of the formal supporting regulatory guidance such as CMS's signature requirements.

Good Luck!
 
Signature requirements for Operative Reports and Inpatient Consults

Hello I am hoping someone can help me. I have an Office Manager stating that I should be billing out these reports without the doctor electronically signing off on them. That its their bread and butter and need the A/R out to receive payment.

Can I just bill out after coding the operative report after it has been dictated? I have sent her the MLM6689 (I believe it is) but saying that is how they use to do it and I should too. I do not feel comfortable billing out after it has been dictated and the doctor hasnt reviewed, the same for an Inpatient Consult. Ive seen doctors come back and amend their consult after they review other 'reports'.

any help would be appreciated.
thanks
 
Signature requirements for Operative Reports and Inpatient Consults

You should not even be coding / abstracting from Operative reports or for that matter any notes that are not final signed / authenticated by the provider.

Your office manager should address this with the providers involved as this is poor practice.

If this is a teaching institution and teaching physician supervision attestations are not appropriately appended at the time of final sign then these services are not even billable.

Maria CPC, CPC-H, CPCO, CPMA, CEMC
 
Where is this found?

Maria, I am curious where you found this regulation, as I have been searching for this as well. Is this an internal policy of your organization? Also, to throw another wrench in the process, here is one argument I have been given for not waiting for a signature on the progress note or operative report - the provider is already acknowledging the services on the CMS-1500 are correct by signing the claim - of course, this is an electronic signature, but he or she is still acknowledging that the claim is correct.
 
Anyone feel free to correct me if I am wrong, but there is nothing published regulating an acceptable timeframe for physicans to sign their medical records. Here is about the closest thing I could find - http://www.cms.gov/Outreach-and-Edu...k-MLN/MLNMattersArticles/downloads/MM6698.pdf - which is a revised version of MLN6698 that was also referenced above.

As others have mentioned, I would not make it a practice to submit claims for unsigned medical records. Most EMRs have a safeguard in place to prevent this, but obviously paper charts do not have this luxury.
 
references to the laws & penalties

martinni1974 said:
There is no real straight answer to this. It falls more on intent and knowledge of what you are submitting.

Regardless of a signature if you as a coder, who holds professional knowledge of coding, documentation, and billing rules knowingly submits non-compliant charges you can be held accountable. Providers like to think they can "protect" you or take blame because as your superior they "told' you to do it and that is simply not so. The laws and penalites that exist apply to not just the provider but any person who knowingly breaks those laws.

I wouldn't run out and quit your job etc but if there is a situation I would document to whom and when education and corrective action was provided to as well as their response to it.

If you have management that you can report to I would also advise them as to what the situation is along with a copy of the formal supporting regulatory guidance such as CMS's signature requirements.

Good Luck!
Click to expand...

Where can I find references to the laws & penalties that would apply?
 
CMS guidelines for NOn Medicare Pts?

I've tried using these guidelines as proof, but my Drs think this only applies to Medicare Pts. Is there any other reference?
 
You must log in or register to reply here.
Top