The Centers for Medicare & Medicaid Services (CMS) has published rules and guidance on the topic of a "completed medical record." But what if the provider didn't sign off on the note or authenticate it in the electronic health record (EHR) until after the fact? Is the record still considered complete, for billing and reporting purposes?
During this edition of Talk Ten Tuesdays, nationally recognized professional physician coder and auditor Terry Fletcher reports on the need for complete medical records, including the proper documentation and a dated physician signature.
This podcast also features the following segments: