Wiki Signature on EMR Encounters

Create Wiki
A

amandalea621

New
Messages
2
Location
Trevose, PA
Best answers
0
Hello,
My CMO asked today why providers had to sign off on the encounters before creating/submitting claims. She read the CMS rule about documentation best practices being 24-48 hours and said we can create/submit claims at the time of service, and providers can sign off later. I told her that would not be compliant, and now I have been tasked with finding official guidance from an accredited organization to prevent this from being implemented. (We have unsigned encounters going back 6 months, which scares me to my core). I thought this would be much easier to find.
 
In order for a medical record to be complete, it must be signed. No billing should be released without signed records.
Specifically, page 3 with my emphasis added:
Documentation Guidelines for Medical Services
We can deny payment for services with incomplete or illegible records. For a claim to be valid, the provider’s or hospital’s records must have sufficient documentation to verify the services performed were compliant with all CMS policies and required the level of care billed. If there’s no documentation or insufficient documentation, then there’s no justification for the services or level of care billed. Also, if providers don’t include sufficient documentation on claims we’ve already paid, we may consider the payment an overpayment, which we can partially or fully recover.

Several MACs also re-iterate this (links embedded):
From Palmetto:
Signature Requirements: Medicare requires that services provided/ordered be authenticated by the author. The signature for each entry must be legible and should include the practitioner’s first and last name.

From CGS:
Signatures and Compliance: Practitioner Offices and Billing Services
It is fairly common knowledge that Medicare requires medical records for services provided and ordered to be "authenticated" by the author. How do these rules apply when the practitioner contracts with a billing service to submit claims and handle documentation requests? Medicare contractors apply the signature guidelines without regard to whether the practitioner, provider, or practice submits its own claims or utilizes a billing service. Regardless of who submits the claim or in what manner it is submitted (paper or electronic), and regardless of whether the provider uses an Electronic Medical Record (EMR) system or a paper-based system, Medicare's signature guidelines apply. Compliance with Medicare's signature guidelines requires a partnership and close communication between health care providers and billing services.

From NGS:
Signature Requirements
Medicare requires that services provided/ordered/certified be authenticated by the persons responsible for the care of the beneficiary in accordance with Medicare’s policies. The treating physician’s/NPP's signature on a note indicates the physician/NPP affirms the note adequately documents the care provided.
 
I would just add that missing signatures continue to be a major cause of post-payment denials. Check your MAC's medical review section for more information.
 
You must log in or register to reply here.
Top