Don't have a TCI SuperCoder account yet? Become a Member >>

Regular Price: $24.95

Ask An Expert Starting at $24.95
Have a medical coding or compliance question? Don’t sacrifice your valuable time to endless research. Choose Ask an Expert to get clear answers from the TCI SuperCoder team. And here’s a tip for the budget-conscious: Select the 12-question pack to get the best rate per question!

Browse Past Questions By Specialty

+View all

Billing for Hosptial Consult and Hospital Visits

Cheryll Posted Tue 09th of June, 2015 15:35:19 PM

Is it possible to code Hospital Consults and Hospital Visits without a physician's signature. What about coding Incident to Hospital Visits and Hospital Consults. Do those need a physician signature?

SuperCoder Answered Tue 09th of June, 2015 17:40:37 PM

Thanks for your question. Medicare requires that any services that are provided or ordered are to be authenticated by the author. This can be with a hand written or electronic signature. If the documentation is not signed, you have no indication that the provider has reviewed and verified that the information is correct. Medicare would disregard the documentation unless they receive a signature attestation. So in short, if there is no signature on the documentation, technically, the provider should not be reimbursed. It is best practice, that a physician sign documentation immediately upon entry or as soon as dictation has been verified following transcription.

Incident-to has its own set of guidelines. If ancillary staff is completing the services, then the supervising physician must sign off on the documentation. If a NPP is completing the services, and billing under incident-to, the NPP or the supervising physician may sign the documentation. Take a look at the CMS guidelines for signature requirements and incident-to billing. Hope this helps.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/se0441.pdf

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Signature_Requirements_Fact_Sheet_ICN905364.pdf

Cheryll Posted Wed 10th of June, 2015 09:55:41 AM

Thank you for your reply. I now would like to know if this also pertains to the commercial carriers or is it possible to bill without a physican signature or in the case of incident to, would the physician need to sign. Thank you!

SuperCoder Answered Fri 19th of June, 2015 06:53:19 AM

I apologize for the delay. Thanks for your patience. Most commercial carriers follow Medicare guidelines when it comes to documentation and signature requirements. You should follow Medicare guidelines in this case unless your commercial carrier has a policy in place that contradicts their guidelines. In general, documentation that does not contain the appropriate signature is considered incomplete and therefore not billable. Hope this helps you.

Related Topics