Some of our doctors use handwritten signatures on their charts and others prefer electronic signatures. How do you go about in this situation? Answer: As per CMS documents, Medicare needs a legible identifier for services provided/ordered. That ‘identifier' or signature can be electronic or handwritten as long as the provider meets some criteria. Readable first and last names, a legible first initial with last name or even an illegible signature over a printed or typed name are acceptable. You are also covered if the provider's signature is illegible but is on a page with other information identifying the signer (letterhead, addressograph and the like)
What's more, be sure to include the provider's credentials. These credentials themselves can be with the signature or they can be identified somewhere else on the note.
For instance: Pre-printed forms might include the doctor's name and credentials at the top, side, or end. All qualify as acceptable documentation so long as the coder or auditor can identify the provider's qualifications.
You can also use a signature log to back up your doctor's documentation. The log should comprise each provider's printed or typed name and credentials, along with their signatures and initials. You can reference the signature log in order to confirm a note that contains an otherwise unrecognizable signature. This is a vital resource when providers are signing notes that don't include their typed or pre-printed name.
Tip: Bring up to date signature logs at least once a year. Make separate logs by provider (doctors, CRNAs, AAs, residents, and the like) to help simplify tracking.
Warning:
Stamped signatures do not meet the CMS requirements; a stamped signature can be used as anyone; therefore does not identify the physician. However, you can use a stamped block print name below the provider's signature to identify an illegible signature.
Do not let EMRs do all your work
Our office is in the process of switching to electronic medical records (EMR) completely. As such, does that cover signature requirements for us?
Answer: Well some coders or providers think that EMRs do all the documentation work for you. However, that's not the case essentially. Even electronic signatures must meet some key requirements. And not all verbiage is equally created.
Considerations: Double check the electronic signature's wording as your providers incorporate EMR in their day to day care. Does it say, ‘Electronically signed by' or ‘Authenticated by'? Does it cover the date? There are various ways of phrasing and formatting the electronic signature. Verify that the format you are implementing is approved by the agency.
Word of caution: Electronic signatures carry the potential for abuse or misuse. System and software products should be safeguarded against unauthorized modifications. Electronic capabilities should also meet recognized standards and laws; check with your healthcare attorney and/or malpractice insurer to prove compliance.
For more question and answers to put you in the right track, sign up for a one-stop medical coding guide like Supercoder.
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