By Carolyn Buppert
Carolyn Buppert, JD, NP is a health care attorney. Her legal clients include medical practices, institutions, non-profit organizations and individual clinicians throughout the United States. She is the author of eight books, and her column offers tips and advice on financial issues. Visit her website to learn more about her: www.buppert.com.
One of the requirements of Medicare and other payers is that each medical service ordered and provided must be “authenticated by the author.” This means that it must be signed by the clinician doing the ordering or performing the procedure. A payer may deny a claim for payment if the medical record is not properly authenticated. The Centers for Medicare & Medicaid Services (CMS) recently issued a MedLearn Matters article (MM6698) on “Signature Guidelines for Medical Review Purposes,” in which their auditors are told what to look for regarding signatures. (The article is available at www.cms.gov/MLNMattersArticles/dowloads/MM6698.pdf)
The MedLearn Matters article contains the following guidance for clinicians. A handwritten signature is defined as a mark or sign by an individual on a document to signify knowledge, approval, acceptance, or obligation. Acceptable methods of signing records/test orders and findings include handwritten signatures or initials and electronic signatures. Signature stamps are not acceptable.
Facsimiles of original written or electronic signatures are acceptable for notes that are used for certification of terminal illness for hospice. Although orders for clinical diagnostic tests do not require a signature, there must be medical documentation for an unsigned order for the test by the treating clinician (ie, a progress note) that he/she intended for the clinical test to be performed. This documentation showing intent that the test be performed must be authenticated by the author via a handwritten or electronic signature. Note also that other regulations and CMS instructions regarding signatures take precedence. If a regulation, National Coverage Determination (NCD), Local Coverage Determination (LCD), or the CMS manual has specific signature requirements, those requirements take precedence.
If a regulation, NCD, LCD, or the CMS manual is silent on whether the signature must be legible or present and the signature is illegible or missing, the auditor will follow the following guidelines to determine the identity and credentials of the signatory.
Auditors are instructed to use the following guidelines regarding signatures.
The second entry is the undated physician visit note. The third entry is a nursing note dated October 4. The reviewer may conclude that the physician visit was conducted on October 4.
Providers sometimes include a signature log that identifies the author associated with the initials or an illegible signature in the documentation they submit. The signature log might be included on the page where the initials or illegible signature are used or might be a separate document. Reviewers will consider all submitted signature logs regardless of the date they were created.
Providers sometimes include an attestation statement in the documentation they submit. In order to be considered valid for Medicare medical review purposes, an attestation statement must be signed and dated by the author of the medical record entry and must contain sufficient information to identify the beneficiary. An accepted format for an attestation statement is as follows:
“I, [name of provider], hereby attest that the medical record entry for [date of service] accurately reflects signatures/notations that I made in my capacity as [provider credentials] when I treated/diagnosed the above-listed Medicare beneficiary. 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.”
Claims reviewers will not consider attestation statements where there is no associated medical record entry or from someone other than the author of the medical record entry in question.
Reviewers will accept as valid any order for Part B drugs through a qualified E-Prescribing system. When Part B drugs have been ordered through a qualified E-Prescribing system, the reviewer will not require the provider to produce a hardcopy pen and ink signature as evidence of a drug order. For Medicare review purposes, a qualified E-Prescribing system is one that meets all 42 CFR 423.160 requirements. (For the rules regarding electronic prescribing of controlled substances, visit www.deadiversion.usdoj.gov/ecomm/e_rx/index.html)
Medicare contractors may have signature requirements in addition to those described above. For example, the following requirements are from Palmetto GBA.
The signature for each entry must be legible and should include the practitioner’s first and last name. For clarification purposes, we recommend inclusion of applicable credentials, eg, PA, DO, or MD.
Electronic signatures usually contain date and time stamps and include printed statements, eg, “electronically signed by” or “verified/reviewed by,” followed by the practitioner’s name and preferably a professional designation.
Note that the responsibility and authorship related to the signature should be clearly defined in the record.
I have chosen to provide this information because it would be a shame for a nurse practitioner to spend time writing a detailed note, only to have the claim for payment denied because of a signature problem.