Practice of Medicine
Completing Records for Billing Following an Unforeseen Physician Departure
Organizations are occasionally faced with the immediate termination or abrupt departure of a physician or licensed clinician (“departed physician”). When that happens, there may be open, incomplete charts left behind. It is important to take immediate steps to complete those charts for patient safety, continuity of care, and billing purposes. This guidance focuses on ensuring the charts are appropriate for reimbursement submissions.
In order to properly submit a claim for reimbursement, the patient’s medical record encounter must be “closed” and include a valid physician signature. It is likely that a departed physician will have open medical records that are not “closed,” and thus the open medical record encounter does not include the populated physician signature required for billing. A valid signature authenticates the service and is handwritten or electronically signed. There are two main options available to organizations when they are left with open charts.
Option 1: Obtain Attestation from the Departed Physician
The organization should attempt to have the departed physician attest to the medical record(s). The departed physician’s attestation will stand in place of a physical signature. The attestation should be dated and signed by the departed physician, and the document should contain sufficient information to identify the patient. The departed physician will need to include accurate, true, and complete information regarding the treatment or diagnosis of the patient. If the departed physician is willing to attest to the medical record, the medical record may be closed and the practice may bill for the service provided under the departed physician’s billing information. For illustrative purposes, the following sample attestation would be valid.
“I, [full name of the physician/practitioner], hereby attest that the medical record entry for [date of service] accurately reflects signatures/notations that I made in my capacity as [provider credentials, e.g., M.D.] when I treated/diagnosed the above-listed patient. I do hereby attest that this information is true, accurate and complete to the best of my knowledge and I understand that any falsification, omission, or concealment of material fact may subject me to administrative, civil, or criminal liability.”
Though the medical record has properly been closed for patients treated by the departed physician, the organization should remain aware of the patient’s medical care needs. The organization should have an internal protocol to transfer the patient to another provider to ensure ongoing care, inform the patient about diagnoses and lab results, continue to prescribe medication, etc. A strong internal protocol with respect to appropriately transitioning patients and ensuring continuity of care can help limit liability for the practice with respect to claims such as patient abandonment and delay in diagnosis.
Option 2: Another Physician Should Appropriately Close the Encounter
If the departed physician is not willing to attest to the medical record(s), another physician in the organization may access the medical record and take the appropriate steps to close the medical record. The new physician may need to include pertinent amendments, corrections, or addenda to the medical record before the medical record may be properly closed. These alterations should be clearly and permanently documented with the new physician dating and signing the medical record and utilizing the new physician’s billing information. The original content created by the terminated physician should not be deleted in any way. In dealing specifically with electronic medical records, corrections should provide a reliable means to identify the original work by the terminated physician, the new content, and the date and author of each entry. The practice may now bill for the services rendered or ordered with the new physician’s signature and billing information.
If the incompleteness of the medical record left by the departed physician does not allow the new physician to ascertain what medical care was provided to the patient, the new physician should take reasonable steps to obtain the needed information, not just assume. They may have to communicate with the patient about medical services rendered. In some situations, they may have to re-administer exams and services to ensure accurate medical information is obtained. After obtaining the needed information, the physician may close the medical records in the manner mentioned before.
The practice should ensure that the new physician understands the patient is now under their care and their responsibility. All medical care moving forward should be provided by that physician or transferred to another who can provide ongoing care. For example, the new physician will be responsible for informing the patient of lab results and diagnostic tests. Likewise, the physician will assume future appointments that the patient had already scheduled with the practice. If the physician is unable to assume responsibility for the patient, the practice should ensure the patient is transferred to another provider who is able to ensure the appropriate medical care continues for the individual.
Best practices to ensure smooth transitions and regulatory compliance:
- Have policies in place that encourage physicians to properly close medical records in a timely manner
- Provide periodic training and conduct audits to ensure physicians are educated on and closing medical records timely and appropriately.
- Have procedures in place to ensure a patient is transferred to a new physician once the organization is aware of the current physician’s departure.
- Provide timely notification to patients of a physician's departure and steps the organization is taking to ensure continuity of care.
- Ensure procedures are in place to always communicate and document patient test results and follow-up care.
- If paper records are being utilized, maintain a signature log to aid in establishing signature legibility.
1. Medicare Administrative Contractor Guidance on Medical Documentation Signature Requirements
2. CMS Manual Provision Regarding Signature Attestation Requirements, see page 46
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The information provided in this resource does not constitute legal, medical or any other professional advice, nor does it establish a standard of care. This resource has been created as an aid to you in your practice. The ultimate decision on how to use the information provided rests solely with you, the PolicyOwner.