Urology Coding Alert: Verify Your Group's Signature Compliance

By Author: Leesa Israel
Total Articles: 4
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Be careful of EMR signature pitfalls.


Including provider signatures is a basic documentation requirement for your patient charts as well as daily challenge. Here's how you can verify your group's signature compliance.


According to CMS documents, "Medicare needs a legible identifier for services that are provided/ordered." That "identifier", or signature, can be electronic or handwritten, as long as the provider fulfils certain criteria. Readable first and last names, a Readable first initial with last name, or even an unreadable signature over a printed or typed name are adequate and acceptable. Moreover, you're also covered in case the provider's signature is illegible but is on a page with further information classifying the signer (letterhead, addressograph, etc.).


Ensure that you include the provider's credentials. The credentials can be with the signature or they can also be identified elsewhere on the note.


Example: Pre-printed forms might list the physician's name and credentials anywhere: at the top, side, or end. All of these ...
... qualify as standard documentation as long as the coder or auditor is able to identify the provider's credentials.


You can also use a signature log to support your urologist's documentation. The log should cover each provider's printed or typed name and credentials as well as their signatures and initials. You can reference the signature log to verify a note that includes an otherwise unidentifiable signature.


Tip: You should update signature logs at least once a year. Make distinct logs by provider (physicians, CRNAs, AAs, residents, etc.) to make the tracking easier.


Remember: Stamped signatures don't meet the CMS requirements because anyone who has an access to the stamp, could use it. It doesn't validate that the billing provider was himself the author of the supporting documentation. You can, though, use a typed or printed block print name under the provider's signature to noticeably identify an illegible signature.


Don't Let EMRs Do All Your Work


Some coders -- or providers -- consider that electronic medical records (EMRs) do all the documentation work, but that's not essentially the case. Even electronic signatures must fulfil certain requirements.


Considerations: As your providers include EMR in their everyday care, you should double check the electronic signature's wording. It should say ‘Electronically signed by' or ‘Authenticated by' also include the date.


There are multiple ways of phrasing and formatting the electronic signature. You should verify that the format you're implementing is accepted by CMS.


Warning: Electronic signatures could be misused or abused. The safety of system and software products against unauthorized modifications should be ensured. Electronic capabilities should follow recognized standards and laws. You should consult your healthcare attorney and/or malpractice insurer to ensure compliance.


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