Health Information Management

Q&A: Unsigned notes

CDI Strategies, October 29, 2015

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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. 



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