Certified Risk Adjustment Coder (CRC)

What occurs if a medical record lacks a provider's signature during a RADV audit?

1. The record is automatically accepted

2. It leads to immediate reimbursement denial

3. An attestation from the provider is required

4. There are no consequences for missing signatures

The correct answer is: An attestation from the provider is required

A medical record that lacks a provider's signature during a Risk Adjustment Data Validation (RADV) audit does indeed require an attestation from the provider. An attestation is a statement confirming the accuracy of the documentation and serves to validate the services rendered, even in the absence of a signature. This process is crucial for upholding the integrity and accountability of medical records in the context of risk adjustment and reimbursement. In this scenario, the absence of a signature does not automatically render the record invalid or accepted without review, which reinforces the importance of having a provider's verification. Instead, it opens a pathway for the provider to confirm the details through an attestation, ensuring that the necessary documentation standards are enforced while allowing for some flexibility in record-keeping practices. This approach protects both the provider's interests and the integrity of the coding and reimbursement processes by ensuring that there is a method of validation even when one element is missing. Understanding this requirement underscores the need for both providers and coders to prioritize thorough documentation practices, such as ensuring signatures, while also being prepared to address any omissions effectively through attestations when necessary.