With late signatures, can you still bill for your medical services?

Late physician signatures pose serious issues.

In the last few months, I have had questions about late signatures on documentation come in from several clients.

I’ve been hearing about providers signing their notes a very long time after the encounter – sometimes weeks later, sometimes months,  and sometimes even turning them in unsigned on an additional documentation request (ADR).

Centers for Medicare & Medicaid Services (CMS) guidance on the topic of a completed medical record and what we have all heard described as the standard of practice tells me that providers are not supposed to be allowed to sign their medical chart notes after the fact.

However, as I started to research this topic further, I found that routinely, when clinics and practice in-house auditors catch it, they generally just let the provider attest to it and let it go. Is this really compliant? And is “letting it go” or allowing this behavior of late signatures hurting or helping your physicians?

So let’s look at the rules surrounding signing a note or patient encounter, from the general documentation guidelines.

For billing purposes, Medicare generally requires the following:  

  1. The medical record should be complete and legible.
  2. The documentation of each patient encounter should include:
    • Reason for the encounter and relevant patient history, physical examination findings, and prior diagnostic test results;
    • Assessment, clinical impression, or diagnosis;
    • A plan for care; and
    • A date and legible identity of the observer.

While the issue of legibility has been largely addressed by increased utilization of electronic health records (EHRs), completion of the record through the inclusion of proper documentation and a dated signature continues to be of concern. What does it mean for a medical record to be complete? Is the record complete when it contains the documentation of the patient encounter but is not signed and dated? 

As you know, you should not bill for an office visit or other services until documentation is on file supporting the level of service or code indicated for billing. The file is not complete until the proper documentation is accompanied by a dated signature. The question then becomes, “how long does the provider have to sign and date the record in order for it to be accepted by CMS or any payor?” 

The question is important because the EHR systems I work with do not allow for back-dating of a signature, meaning that as I audit a record, I know exactly when the signature of the provider was placed in the record. 

If you go to the website of your Medicare Administrative Contractor (MAC), you might find the answer. The CMS/Medicare policy manual is intentionally vague to allow the regional MACs’ medical directors the opportunity to set policy for their regions. As a result, the answer as to timing varies from region to region. CMS’s vague guidance is found in Chapter 12 of the Manual in the following statement: “the service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record.” This means they do not want the physician to forget details by waiting to sign off. 
 
Also, some payors have put on their websites their own interpretations of what they enforce. Some give reasonable direction, like:

  1. WPS (Wisconsin Physician Services) says “a reasonable expectation would be no more than a couple of days away from the service itself.” 
  2. Noridian, which is one of the biggest MACs in the country, and my Medicare payor here in California, states that they expect “in most cases, the notes would be signed at the time services are rendered.” I notice that Nordion adds, “further delays may require an explanation,” which is almost baiting a physician in how vague it is.
  3. Palmetto is a little more direct, stating that “providers should not add a late signature to the medical record (beyond the short delay that occurs during the transcription process).”
     

It is understood that there are circumstances, such as waiting for transcription to be complete, that might preclude signing the record at the time of service. In general, it is best to sign the record at the time of service, or within a day or two at the latest.

I also educate my clients that signatures beyond a couple of days increase the likelihood that a claim will be denied because necessary documentation will not be accepted as being complete due to a signature and date that is too far removed from the time the care was provided. This could be disastrous and costly, in an audit. 

For example, if every note that had a signature older than three days after the service was provided was not accepted by the MAC, then the provider’s documentation of work that was done at the time of the visit with the patient would not be allowed. As a result, there would be no accepted documentation for the visit, and payment would not be allowed even if an attestation statement was added at a later date.

I make sure my clients know that I will enforce a policy that holds all of the providers in their offices to a standard time period of no more than 48 hours to have a signature on the chart. I am pretty strict about it. If they do not want to adhere to the policy, I drop them as a client. I have to be able to support and appeal any record that is questioned, and without mandatory policies like this, it can give physicians too much rope to basically hang themselves out to dry. Accountability is key. 

Having internal policies in place to make sure this is not an issue for your practice is crucial. A complete record should include a physician’s signature or an electronic authentication of the record.

Programming Note:

Listen to Terry Fletcher report this story live today during Talk Ten Tuesday, 10-10:30 a.m. EST.

Facebook
Twitter
LinkedIn

Terry A. Fletcher BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMSCS, ACS-CA, SCP-CA, QMGC, QMCRC, QMPM

Terry Fletcher, BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMSCS, CMCS, ACS-CA, SCP-CA, QMGC, QMCRC, is a healthcare coding consultant, educator, and auditor with more than 30 years of experience. Terry is a past member of the national advisory board for AAPC, past chair of the AAPCCA, and an AAPC national and regional conference educator. Terry is the author of several coding and reimbursement publications, as well as a practice auditor for multiple specialty practices around the country. Her coding and reimbursement specialties include cardiology, peripheral cardiology, gastroenterology, E&M auditing, orthopedics, general surgery, neurology, interventional radiology, and telehealth/telemedicine. Terry is a member of the ICD10monitor editorial board and a popular panelist on Talk Ten Tuesdays.

Related Stories

Leave a Reply

Please log in to your account to comment on this article.

Featured Webcasts

2026 IPPS Masterclass 3: Master MS-DRG Shifts and NTAPs

2026 IPPS Masterclass Day 3: MS-DRG Shifts and NTAPs

This third session in our 2026 IPPS Masterclass will feature a review of FY26 changes to the MS-DRG methodology and new technology add-on payments (NTAPs), presented by nationally recognized ICD-10 coding expert Christine Geiger, MA, RHIA, CCS, CRC, with bonus insights and analysis from Dr. James Kennedy.

August 14, 2025
2026 IPPS Masterclass Day 2: Master ICD-10-PCS Changes

2026 IPPS Masterclass Day 2: Master ICD-10-PCS Changes

This second session in our 2026 IPPS Masterclass will feature a review the FY26 changes to ICD-10-PCS codes. This information will be presented by nationally recognized ICD-10 coding expert Christine Geiger, MA, RHIA, CCS, CRC, with bonus insights and analysis from Dr. James Kennedy.

August 13, 2025
2026 IPPS Masterclass 1: Master ICD-10-CM Changes

2026 IPPS Masterclass Day 1: Master ICD-10-CM Changes

This first session in our 2026 IPPS Masterclass will feature an in-depth explanation of FY26 changes to ICD-10-CM codes and guidelines, CCs/MCCs, and revisions to the MCE, presented by presented by nationally recognized ICD-10 coding expert Christine Geiger, MA, RHIA, CCS, CRC, with bonus insights and analysis from Dr. James Kennedy.

August 12, 2025

Trending News

Featured Webcasts

The Two-Midnight Rule: New Challenges, Proven Strategies

The Two-Midnight Rule: New Challenges, Proven Strategies

RACmonitor is proud to welcome back Dr. Ronald Hirsch, one of his most requested webcasts. In this highly anticipated session, Dr. Hirsch will break down the complex Two Midnight Rule Medicare regulations, translating them into clear, actionable guidance. He’ll walk you through the basics of the rule, offer expert interpretation, and apply the rule to real-world clinical scenarios—so you leave with greater clarity, confidence, and the tools to ensure compliance.

June 19, 2025
Open Door Forum Webcast Series

Open Door Forum Webcast Series

Bring your questions and join the conversation during this open forum series, live every Wednesday at 10 a.m. EST from June 11–July 30. Hosted by Chuck Buck, these fast-paced 30-minute sessions connect you directly with top healthcare experts tackling today’s most urgent compliance and policy issues.

June 11, 2025
Open Door Forum: The Changing Face of Addiction: Coding, Compliance & Care

Open Door Forum: The Changing Face of Addiction: Coding, Compliance & Care

Substance abuse is everywhere. It’s a complicated diagnosis with wide-ranging implications well beyond acute care. The face of addiction continues to change so it’s important to remember not just the addict but the spectrum of extended victims and the other social determinants and legal ramifications. Join John K. Hall, MD, JD, MBA, FCLM, FRCPC, for a critical Q&A on navigating substance abuse in 2025.  Register today and be a part of the conversation!

July 16, 2025

Trending News

Prepare for the 2025 CMS IPPS Final Rule with ICD10monitor’s IPPSPalooza! Click HERE to learn more

Get 15% OFF on all educational webcasts at ICD10monitor with code JULYFOURTH24 until July 4, 2024—start learning today!

CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24