Comments on: The Long Overdue CMS Signature Requirements

By: Paul Spencer, CPC, CPC-H

Paul Spencer, CPC, CPC-H — Wed, 08 Sep 2010 13:44:34 +0000

JHACO requires that all documentation be signed within 30 days following patient discharge. The physician signature requirement affects all documentation of physician services. If the physician in question was the attending physician during the patient’s stay, and if your particular face sheet contains a physician authentication block of some kind for patient discharge, and there is a hospital compliance policy stating that this sheet needs to be signed upon discharge by the attending, then I would have the physician sign the face sheet.
Usually, only the admitting diagnosis and authentication is seen on face sheets, as this sheet is used primarily for identification.

By: Dorothy

Dorothy — Tue, 07 Sep 2010 23:07:57 +0000

Is this requirement for orders only, or does it apply to the physician signing an inpatient chart face sheet after discharge?

By: J. P. Spencer

J. P. Spencer — Tue, 27 Jul 2010 17:25:21 +0000

Great question.

In reviewing the regulation, CMS states only that providers should not add late signatures to the medical record beyond the short delay that occurs during the transcription process. There is no set-in-stone time deadline, but it’s important to keep in mind that any documentation that lacks either a handwritten or electronic signature is considered “not authenticated” by CMS, OIG & the RAC’s.

The same rule applies to physician signature that applies to the documentation of the service: if it doesn’t exist, it didn’t happen.

By: Stephenie

Stephenie — Tue, 27 Jul 2010 16:55:58 +0000

Do you know if there is any information on the time frame for a signature. For example; Provider sees patient today but does not sign the note until two weeks later. Is there a 72 hour rule or a another time frame that is documented that I could use for training??

Thanks
Stephenie