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Identify post-ICD-10 coding and documentation risks

Physician Practice Insider, December 29, 2015

Risk: The record does not contain a legible signature with credential

Review: Per CMS' requirements in the Medicare Program Integrity Manual Chapter 3, Verifying Potential Errors and Taking Corrective Actions for signature requirements, which was updated and implemented August 25, 2015, "For medical review purposes, Medicare requires that services provided/ordered be authenticated by the author. The method used shall be a handwritten or electronic signature. Stamped signatures are not acceptable." The instructions from CMS are specifically for CMS, however, these instructions can easily be put into place as a valid process for all signature authentications for a best practice in your office.

In addition, providers should not add late signatures to the medical record beyond the short delay that occurs during the transcription process. Instead, they should make use of the signature authentication process. The signature authentication process described below should also be used for illegible signatures.

This article was originally published on JustCoding.

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