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02/07/2019

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When to Sign Charts

By Hamilton Lempert, MD, Chief Medical Officer, Coding Policy

We all know the facilities in which we work will eventually track us down for a signature on a chart. But did you know that some payers require that charts be signed within 48 hours?

In such instances, if you do not sign the chart within the specified timeframe, the charts cannot be billed. So, if you do not sign your chart until three days after you see a patient, the chart is unbillable.

Unbilled charts mean that you will not receive relative value unit (RVU) credit for the chart. What’s the number one reason why a chart cannot be billed? Missing signatures. For you to receive appropriate credit for the patients you see, you must sign your documentation. No one else can sign your charts for you.

Although not all charts need to be signed within 48 hours, it is impossible to know which charts require it at the time of service. Therefore, to be safe, make it a best practice to sign all of your charts before you leave at the end of your shift.

In cases where signing before the end of your shift is not possible, ensure that you have remote access to the electronic health record (EHR) or make arrangements to come back to the facility to sign your charts before the 48-hour deadline.

If process issues prevent you from providing a timely signature, go to your Facility Medical Director (FMD), Regional Medical Director (RMD), Vice President of Operations (VPO) or Clinician Documentation Educator (CDE).

I realize that at the end of a busy day or night, the last thing you want to do is to sign your charts, but please sign your charts before you go home. This ensures that all your hard work is properly credited.

To learn more about how TeamHealth supports clinicians in billing, contact phyjobs@th.com.