Insufficient documentation is one of the top issues leading to overpayments with payors on the lookout for any missing info in patients’ records. The biggest reason why provider documentation doesn’t hold weight usually has nothing to do with the codes selected and everything to do with a missing signature.
All medical notes must have an authorized signature. If any note in the medical record does not have an authorized signature, it will not be counted as valid documentation for the encounter.
When you’re performing self audits of your practice’s claims, make sure provider signatures are exactly where they should be. If a signature is missing during a self audit, you cannot simply have the provider add it. Signatures listed after the fact raise red flags for payors. Instead of adding signatures in, have your provider fill out and sign an attestation statement saying that he or she is the person who entered the data in the medical record for the patient on that date, and that all the information entered is valid. Keep this statement with the documentation for the encounter so it is easily accessible.