Q&A: Unsigned notes
CDI Strategies, October 29, 2015
Want to receive articles like this one in your inbox? Subscribe to CDI Strategies!
Q: Is there guidance on reviewing a record, such as an operative (OP) note, that has not been signed by a physician? I am at a facility that allows coding from unsigned transcriptions. I was always told that the information needs to be confirmed by a signature as valid before including that information in the review worksheet. Do you have any recommendations for this?
A: I would not advocate assigning codes based on unsigned OP notes. I believe that several organizations do allow this, so as not to hold up billing waiting for a signature, but I would want a method to ensure the notes get signed.
CMS requires that any Medicare service provided or ordered must be authenticated by the author—the individual who provided or ordered the service. Authentication may be accomplished through the provision of a hand-written or an electronic signature; however, stamp signatures are unacceptable, with the exception of a physical disability.
The information you need from the OP note may also be found on other areas of the record, including the pre-op and post-op progress notes.
Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, and CDI Education Specialist at HCPro in Danvers, Massachusetts, answered this question. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps visit www.hcprobootcamps.com/courses/10040/overview.
Want to receive articles like this one in your inbox? Subscribe to CDI Strategies!
Related Products
-
Briefings on APCs
Worried about the complexities of the new rules under OPPS and APCs? Briefings on APCs helps you understand the new rules...
-
HIM Briefings
Guiding Health Information Management professionals through the continuously changing field of medical records and toward a...
-
Briefings on Coding Compliance Strategies
Submitting improper Medicare documentation can lead to denial of fees, payback, fines, and increased diligence from payers...
-
Briefings on HIPAA
How can you minimize the impact of HIPAA? Subscribe to Briefings on HIPAA, your health information management resource for...
-
APCs Insider
This HTML-based e-mail newsletter provides weekly tips and advice on the new ambulatory payment classifications regulations...
Most Popular
- Articles
-
- Practice the six rights of medication administration
- What to include on the incident report
- Code diagnoses and outpatient treatment for PTSD
- OB services: Coding inside and outside of the package
- Differentiate between types of wound debridement
- Complications from immobility by body system
- Don’t forget the three checks in medication administration
- Note similarities and differences between HCPCS, CPT® codes
- Nursing responsibilities for managing pain
- Coding, billing, and documentation tips for teaching physicians, interns, residents, and students
- E-mailed
-
- New Book Release:Shared Governance: The Essentials for Building Competencies and Measuring Progress
- What to expect when coding CAD, MI with ICD-10-CM
- Reappointment processes for
- Note from the instructor: Billing Outpatient Laboratory Services - TOB 131 vs. TOB 141
- Immediate Jeopardy - Why this finding can be disastrous to your facility.
- Disclosure Law Improves Nurse Staffing Ratios in New Jersey
- Complications from immobility by body system
- AORN expects to make revisions to its guildeline for OR headwear
- Searched
