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Pay Attention to Medicare Signature Requirements

In a recent compliance officers meeting with Kentucky physicians and hospitals, CGS Medicare Part B Medical Director Dr. Earl Berman said all electronic health records should be signed/closed within two days of when the service was provided.

As electronic health records have developed and improved, the focus of electronic signatures was often on systems and software products that must include protections against modification, and other administrative safeguards. The Centers for Medicare and Medicaid Services (CMS) directs physicians to the Program Integrity Manual Publication 100-08 Chapter 3 and Sections E-F for guidelines on electronic signatures.

Although CMS does not provide exact timeframes for signing and closing the electronic health record, the reality is that physicians are expected to complete the documentation of services “during or as soon as practicable after the service is provided in order to maintain an accurate medical record.” This statement is from the CMS Internet-Only Manual (IOM) Publication 100-04, Chapter 12, and Section 30.6.1.

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