Awareness : Did You Know?

Did You Know? Weekly Educational Series 11

For the Week of October 26, 2015

Signature Requirements and Timeliness of Documentation

“Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported. The service should be documented and authenticated during, or as soon as practicable after it is provided in order to maintain an accurate medical record.”

In addition, CMS has a statement in the IOM Publication 100-08, Chapter 3, Section 3.3.2.4 discussing the requirements for practitioner signature, “Providers should not add late signatures to the medical record, (beyond the short delay that occurs during the transcription process) but instead should make use of the signature authentication process.”

The IOM Publication 100-08, Chapter 3, Section 3.3.2.5 discussing late entries. A provider should never add a signature to a medical record after the times discussed above. If a practitioner does not affix a signature at the time of the service (also allowing limited delay due to transcription), then the provider may complete an attestation statement.