Follow these guidelines to avoid errors on medical record entries for physician office infusion therapy services

By following the “BCBSM Documentation Guidelines for Physicians and Other Professional Providers,” available through your online provider manual, you’ll avoid mistakes that could result in a potential audit recovery. The current guidelines for medical record entry, as they apply to physician office infusion therapy services, are summarized and expanded upon below. Each medical record entry, including verbal orders, instructions and dictation, must include:

• The date and actual time of infusions or injections
• A signature, which should be legible and easily authenticated. (By using a first name only, the entry is considered incomplete.)
• BCBSM accepts written (cursive or printed) or computer (electronic) signatures. We don’t accept stamped signatures.
• Electronic signatures:
• The system must verify the electronic signature at the end of each note. An acceptable signature should have one of the following lead-in phrases: “electronically signed by,” “authenticated by,” “approved by,” “completed by,” “finalized by” or “validated by.” This should be followed by the provider’s name, credentials and date signed.
• The process must be password-protected and used exclusively by the individual physician.
• Credentials of the person administering the drug (for example, “Mary Jones, P.A.”)
• A patient ID on each page of the medical record, including test data and reports

Documentation created after the first notification (by phone, mail or fax) of an audit won’t be accepted as part of the medical record.

For more information, please see the “Documentation Guidelines for Physicians and Other Professional Providers” chapter in your online provider manual. To view the chapter:

• From web-DENIS, click on BCBSM Provider Publications and Resources.
• Click on Provider Manual.
• Click on Provider Type and select yours from the “Make Selection” box.
• Click on the Search button and then on the "Documentation Guidelines for Physicians and Other Professional Providers" chapter.