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Question: I was told that providers had to sign off on the encounters before creating/submitting claims. My supervisor read the Centers for Medicare & Medicaid Services (CMS) rule about documentation best practices being 24-48 hours and said we can create/submit claims at the time of service, and providers can sign off later. I told them that would not be compliant, and now I have been tasked with finding official guidance from an accredited organization to prevent this from being implemented. (We have unsigned encounters going back six months, which scares me to my core). I thought this would be much easier to find. Please help!

Tennessee Subscriber

Answer: Yes, it is true that providers must sign off on encounters and/or medical records before claims are submitted. According to , 鈥淔or a claim to be valid, the provider鈥檚 or hospital鈥檚 records must have sufficient documentation to verify the services performed were compliant with all CMS policies and required the level of care billed.鈥� In other words, without adequate or complete documentation, there is no validation for the services or level of care charged. Moreover, if providers fail to provide comprehensive documentation for claims that have already been compensated, they may view this as an overpayment, and they reserve the right to recoup some or all of the payment. 

Lindsey Bush, BA, MA, CPC, Development Editor, AAPC