Dating and signing diagnostic test orders

If the order is sent over ahead of time, there is usually time to correct the missing information.

If the patient brings the order with him or her, this is where we need a fax back form if the order is not complete.

Consider MAC and Med Learn guidance Trail Blazer Health Enterprises, LLC, provided the following guidance in July for documentation requirements: The ordering physician must maintain documentation of medical necessity in the beneficiary’s medical record.

The laboratory must maintain the documentation it receives from the ordering physician and must ensure the information listed on the claim accurately reflects the documentation it received from the ordering physician.

Understand when coders need to verify signatures Regardless of specialty, most coders will at some point need to review a medical record and verify that there is a proper signature from the ordering provider when certain tests or drugs are relevant for code assignment.

For lab services, providers’ offices often fax orders ahead of time or patients will present with the actual orders.

For example, the physician may document in the medical record that he or she ordered specific services.

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The following handwritten signature examples meet the requirement: There are also some examples of acceptable illegible signatures that sufficiently indicate the identity of the signator. Smith has to go into the EMR and “close” the note that Dr. Smith, is the one who examined the patient for the actual visit, not Dr. However they both are responsible for the information provided in the EMR. In the documentation, providers will sometimes include a signature log that identifies the author associated with initials or an illegible signature.

He or she must also authenticate this notation by a handwritten signature or e-signature.

In a retrospective MAC or RAC audit , for example, the auditing party can request monies back if it determines that the documentation is unsatisfactory and outside of the new guidelines.

For example, an illegible signature may appear on a prescription. White puts his electronic signature on the record and states that he scribed the note for the visit for Dr. The signature log might be included on the same page where the initials or illegible signature appear or might be a separate document.

The prescription letterhead may list three physicians along the top, with one of the names circled. However, if a physician provides an illegible signature, but it does not appear over a typed/printed name and he or she does not submit it with a signature log or an attestations statement, this would not satisfy physician signature requirements. Providers using an electronic system must understand the propensity for misuse or abuse with the availability of alternate signature methods. Reviewers will consider all submitted signature logs regardless of creation date. Green rounds on patient A in the hospital after surgery. Green generates a progress note subsequent to his progress note from the day before on patient A. Green signs with an illegible signature in addition to several initialed dates of service.

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