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Comments on Do I have to Sign my Notes?

February 10, 2011

Provided by Jackie Thelian, President of Medco Consulting, Inc.

Hi Jennifer:

It is surprising how many physician/providers do not fully understand the importance of signing their notes. I am glad you addressed this issue.

I would also like to add the following:

CMS Transmittal #248 published on March 28, 2008 addresses the use of signature stamps. The document states, “ Medicare requires a legible identifier for services provided/ordered. The method used shall be handwritten or an electronic signature (stamp signatures are not acceptable) to sign and order or other medical record documentation for medical review purposes”.

Another area of concern is the use of “Dictated but not read”. It is important to note that this does not constitute a signature and as such the documentation can not be counted towards any level of service reported for reimbursement. Additionally, the physician/provider is responsible for the dictated report and its contents as it relates to the history, physical, medical decision (assessment and plan) and therefore should assure the accuracy of the dictation.

So it is important for the physician/providers to remember the following:

1. Make sure to authenticate your notes with either a handwritten signature or an electronic signature

2. Do not use a signature stamp

3. Remember, “dictated but not read” does not constitute a signature

Medco Consultants is endorsed by more societies and associations in NY than any other coding company. If you call Medco, be sure to mention if you belong to a local society, as discounts are extended). Continuing education offered by Medco is essential for your staff and yourself about documentation and billing practices is also essential, especially with ICD-10 coming.

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Provided by Louis Burke, President of ECentral Medical Management:

Jennifer, a notable exception to the handwritten or electronic signature rule is that facsimiles of original written or electronic signatures are acceptable for the certifications of terminal illness for hospice. The facsimile along with hard copies of the physicians electronic signature must be in the patient’s medical record.

Other tips I'd like to pass along that I’ve gathered from James Bavasso “the Medicare Man” is to PRINT the provider’s name under the signature especially if in a group. It’s not documented anywhere in the Medicare policies to my knowledge so I was skeptical until a few reviews for FACE-TO-FACE services (9935…prolonged physican services) that we bill for our oncology clients came back denied for signatures not being legible and informed all of our clients to print under signatures from then on, especially if sending in the notes for review. Lastly Mr. Bavasso said to use blue ink – so that its easier to tell its an original signature as opposed to a copy.

Contact Louis to learn about ECM Total solutions for Medical Practices at 718.525.8567 or louisb@ecmmgt.com. E Central Medical Management regularly provides consultation services for healthcare practitioners for all practice billing issues.

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For additional information on this topic, contact Jennifer Kirschenbaum at (516)-747-6700 ext. 302 or at Jennifer@Kirschenbaumesq.com.

Copyright © 2011 by Kirschenbaum & Kirschenbaum, P.C.
All Rights Reserved. This email is provided for news and information purposes only and does not constitute legal advice or an invitation to an attorney-client relationship. While every effort has been made to ensure the accuracy of the information contained herein, Kirschenbaum & Kirschenbaum PC does not guarantee such accuracy and cannot be held liable for any errors in, any reliance upon this, or losses caused by the information. Under New York’s Code of Professional Responsibility, this material may constitute attorney advertising. Prior results do not guarantee a similar outcome.


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