This must also be authenticated by the author via a handwritten or electronic signature. Providers may submit a signature log or attestation to support the identity of the signer.
Contractors will be looking for some indication in other documentation to support the identity of the signer. A signature log is a typed listing of provider names followed by a handwritten signature.
A signature log can be used to establish signature legibility as needed throughout the medical record documentation. If your facility doesn't have a signature log currently in place, MR will accept all submitted signature logs regardless of the date they were created. While the creation of the log may be a time consuming process, the end result will be that claims with illegible signatures will be processed more quickly than those that do not have a signature log.
It is acceptable to attest your signature. Noridian has adopted this guide and formatted it to this interactive Signature Attestation Statement form. The attestation must be signed and dated by the author of the medical record entry and contain sufficient information to identify the beneficiary. MR encourages all providers to carefully review all documentation that is submitted for an ADR to ensure that all orders and services are signed appropriately.
Initial ADR submissions that include a signature log or attestation for claims with illegible signatures will expedite claim processing. When an attestation request is necessary, the time frame for Noridian to complete the review is changed to 45 days rather than 30 days.
All services provided to beneficiaries are expected to be documented in the medical records at the time they are rendered. Occasionally certain entries are not properly documented and will need to be amended, corrected, or entered after rendering the service.
Health record documents submitted containing amendments, corrections, or addenda must clearly and permanently be identified as such, clearly indicate the date and author of the entry, and clearly identify all original content without deletion.
When correcting electronic health records, entries must provide a reliable means to identify the original content, the modified content, and the date and authorship of each modification of the record.
To reduce the amount of documentation overload, many physicians are looking to Medical Scribe services. When a scribe is used by a provider in documenting medical record entries e. Questions may be directed to the Provider Contact Center. If your facility is currently under medical review, contact the Medical Review Examiner assigned to your file.
The guidelines below will assist in determining whether the signature requirements have been met. Before you can enter the Noridian Medicare site, please read and accept an agreement to abide by the copyright rules regarding the information you find within this site. If you choose not to accept the agreement, you will return to the Noridian Medicare home page. All Rights Reserved. You, your employees and agents are authorized to use CPT only as contained in the following authorized materials: Local Coverage Determinations LCDs , training material, publications, and Medicare guidelines, internally within your organization within the United States for the sole use by yourself, employees and agents.
You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. State Street, Chicago, IL Leverage the power of Microsoft Excel by downloading the perfect free log template. Maximize productivity with detailed and organized records.
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