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Click here for more sample CPC practice exam questions and answers with full rationale

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Practice Exam

Click here for more sample CPC practice exam questions and answers with full rationale

Signature requirements for infusion therapy notes

Our independent practice provides infusion therapy services (Tysabri, lidocaine, Solumedrol, etc.). The Infusion Department (RNs) provide the service (96413 for example) in the office suite and bill under the supervising physician. The RN signs the note. Is the supervising (billable) physician required to sign the note as well? If so, I’m looking for documentation of the requirements from CMS.

Thank you for any feedback!

Medical Billing and Coding Forum

Can a Resident admit into the hospital with a Physician signature only?

I have a claim where the Resident did the HPI, ROS, PE, & listed the diagnoses, signed the note. However, the Physician did not attest to this Initial admit, and signed the note 2 days later. Can I bill this claim as a Res Only Admit?

Medical Billing and Coding Forum

Resident signature

We are a teaching hospital and have resident’s seeing patients, documenting the records and then the teaching physician see’s the patient and documents his portion. Sometimes, the supervising physician signs the documentation before the resident does and then the resident can’t sign the note. My question is this. Are resident’s required to sign the documentation and if so, can you point me to the Medicare guidelines that says this. I’ve been looking and can’t find anything that states this. I can only find that the teaching physician must date and sign the note.

Thanks

Medical Billing and Coding

A Signature Is Mandatory on Medical Records

Payers and the Centers for Medicare & Medicaid Services (CMS) require that the medical chart documentation sent to support a claim contain a legible and timely signature. For medical review purposes, Medicare requires the author, using a handwritten or a valid electronic signature, to authenticate the services provided/ordered. Regardless of how accurate the coding is, […]
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