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  • Coding Competency Ask the Expert

    Electronic Signature Policy


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    We received an additional documentation request (ADR) from Centers for Medicare & Medicaid Services’ (CMS) Comprehensive Error Rate Testing (CERT) Documentation Center. For electronic health records (EHR) it asked us to send a copy of our electronic signature policy and procedures that document the process of the physician signature for chart notes and orders. Does the Academy have a sample policy and procedure for EHR signatures?

    Answer:
    When receiving an ADR for an audit, CMS may request your practice's electronic signature policy. This shows your compliance with securing electronic physician signatures, including that there are no shared passwords.

    From Fundamentals of Ophthalmic Coding:
    “Electronic signatures must be authenticated, safeguarded against misuse and modification and easily identifiable as electronic, rather than typewritten signatures. The physician’s password must be secure, as the individual represented by the electronic signature bears the responsibility for the authenticity of the information.”

    Sample policies can be found in the AAOE® Practice Forms Library — Protocols.