Tips for Medical Record Certification

On August 23, 2011, in Medicare, News, Regulations, by admin

Medicare as well as most insurance companies requires physicians and/or providers that order services for patients prove medical necessity in documentation.  The #1 error related to this requirement is not being able to identify the health care provider that ordered the service, through lack of either documentation or where the signature is illegible. Did you […]

Medicare as well as most insurance companies requires physicians and/or providers that order services for patients prove medical necessity in documentation.  The #1 error related to this requirement is not being able to identify the health care provider that ordered the service, through lack of either documentation or where the signature is illegible.

Did you know there are two acceptable forms to authenticate the health care provider’s signature?

Yes, Medicare/CMS accepts, and recommends a signature log or attestation statement alongside a requested submission of medical records should the charges be audited.  This can save the office as well as the auditing entity valuable time and money.  And we are all about saving time and making money, right?

Physician offices may want to create a signature log to help identify the health care provider associated with either initials or signatures that are not legible.  Face it; most physician signatures are not legible.  Having a sheet similar to a ’key’ to a map or a ‘glossary’ of definitions can be used/submitted to an auditing entity alongside medical records for authentication/verification of physician/health care provider signatures.  This can be done as simple as creating a signed and dated document.

An Attestation Statement is also an acceptable form of authenticity where the medical record is lacking or is illegible.  An example of an attestation statement can be found at http://www.trailblazerhealth.com/Tools/Notices.aspx?DomainID=1&ID=14440

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