Urology Coding Alert: Verify Your Group's Signature Compliance

Be careful of EMR signature pitfalls.

Including provider signatures is a basic documentation requirement for your patient charts as well as daily challenge. Here's how you can verify your group's signature compliance.

According to CMS documents, "Medicare needs a legible identifier for services that are provided/ordered." That "identifier", or signature, can be electronic or handwritten, as long as the provider fulfils certain criteria. Readable first and last names, a Readable first initial with last name, or even an unreadable signature over a printed or typed name are adequate and acceptable. Moreover, you're also covered in case the provider's signature is illegible but is on a page with further information classifying the signer (letterhead, addressograph, etc.).

Ensure that you include the provider's credentials. The credentials can be with the signature or they can also be identified elsewhere on the note.

Example: Pre-printed forms might list the physician's name and credentials anywhere: at the top, side, or end. All of these qualify as standard documentation as long as the coder or auditor is able to identify the provider's credentials.

You can also use a signature log to support your urologist's documentation. The log should cover each provider's printed or typed name and credentials as well as their signatures and initials. You can reference the signature log to verify a note that includes an otherwise unidentifiable signature.

Tip: You should update signature logs at least once a year. Make distinct logs by provider (physicians, CRNAs, AAs, residents, etc.) to make the tracking easier.

Remember: Stamped signatures don't meet the CMS requirements because anyone who has an access to the stamp, could use it. It doesn't validate that the billing provider was himself the author of the supporting documentation. You can, though, use a typed or printed block print name under the provider's signature to noticeably identify an illegible signature.

Don't Let EMRs Do All Your Work

Some coders -- or providers -- consider that electronic medical records (EMRs) do all the documentation work, but that's not essentially the case. Even electronic signatures must fulfil certain requirements.

Considerations: As your providers include EMR in their everyday care, you should double check the electronic signature's wording. It should say ‘Electronically signed by' or ‘Authenticated by' also include the date.

There are multiple ways of phrasing and formatting the electronic signature. You should verify that the format you're implementing is accepted by CMS.

Warning: Electronic signatures could be misused or abused. The safety of system and software products against unauthorized modifications should be ensured. Electronic capabilities should follow recognized standards and laws. You should consult your healthcare attorney and/or malpractice insurer to ensure compliance.

Urology Coding Alert : Avoid the Pressure of Choosing Physical Examination Levels

1995 vs. 1997 guidelines: Choose one per claim, but you should feel free to use either one for different claims.

Determining the Physical Examination Level


There are two sets of guidelines you should know before determining the level of the physical examination key element for your E/M coding: 1995 and 1997 medical guidelines.

Both sets of guidelines help you decide which of the following listed four levels of examinations your urologist accomplished during an E/M service:

problem-focused,

detailed,

expanded problem focused,

and comprehensive.

The level of exam is a key factor in determining which code you should report: 99201- 99205 (Office or other outpatient visit for the E/M of a new patient, which needs these 3 basic components …) for new patients or 99212-99215 (Office or other outpatient visit for the E/M of an established patient, which requires at least 2 of these 3 basic components …) for established patients.

1995 and 1997 Guidelines: What's the Difference

The most significant difference between these two sets of guidelines is the exam element.

1997: The 1997 guidelines involve specific physical exam elements that must be addressed in the documentation. If a physician addresses elements other than those specified in the guidelines, the physician will not essentially receive credit for that particular element in the level of service. Also, if the language relating to an exam element included in the documentation is different from the one in the guidelines, an auditor who has not had much clinical experience may reject the element from being credited in the level of service.

1995: The 1995 guidelines are comparatively less restrictive. They let the physician make any comment in any of the designated body areas and/or organ systems he examines. What the physician examines within the areas and systems and the language he or she chooses to document are eventually decided by the physician.

Which Guidelines Should You Use?

It is not required that you pick one set of guidelines and stick with them whenevr you code an E/M service. You can switch between 1995 and 1997 and choose whichever set of guidelines is most beneficial for each encounter.

Important: The key, however, is that, for a single encounter you should use either 1995 or 1997 guidelines. Keep in mind that the guidelines are only for the reporting of the physical examination. The remaining two key components, history and medical decision making, continue to be the same. It doesn't matter which physical examination guidelines you use.

Besides, practices should know if there are any special requirements of their contracts with their insurers.

So which guideline should you use? That also depends on your urologist and how does he document. Usually the 1995 documentation guidelines are going to be more beneficial for most practices. The reason being that they are more flexible and they also reflect the way most physicians were trained to document. However, some physicians may have been trained or may have developed decent documentation practices around the 1997 guidelines, and this may be beneficial to them.

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