CMS Releases Guidance on Signature Requirements
Note: Cahaba GBA is presenting a webinar on the signature guidelines in CR 6698 on June 10, 2010. Providers can register to participate at: https://www.cahabagba.com/apps/course_registration/al/course_summary.jsp?EID=350
On March 16, 2010, CMS finally released additional long-awaited guidance on signature requirements for medical review purposes in Transmittal 327 (CR 6698) that updates the Medicare Program Integrity Manual (PIM). We encourage providers to carefully review the entire transmittal for complete information. Following are some key points from the transmittal.
For medical review purposes, Medicare requires that services provided/ordered be authenticated by the author. The method used shall be a hand written or an electronic signature. Stamp signatures are not acceptable. If a requisition for clinical diagnostic tests (such as laboratory tests) is unsigned there must be signed (handwritten or electronically) medical documentation by the treating physician (e.g. a progress note or order) that clearly documents that he/she intended the clinical diagnostic tests be performed. If another regulation, NCD, LCD or CMS manual has specific signature requirements (e.g. signatures on plans of care must be signed prior to services being rendered), those requirements take precedent over the instruction is the PIM.
- If the signature is missing from an order, the Medicare reviewer (ACs, MACs, PSCs, ZPICs and CERT) shall disregard the order during the review of the claim.
- If the signature is illegible, the reviewer shall consider evidence in a signature log or attestation statement to determine the identity of the author of a medical record entry.
- If the signature is missing from medical documentation other than an order, the reviewer shall accept a signature attestation from the author of the medical record entry.
A signature log lists the typed or printed name of the author associated with initials or an illegible signature. It is preferable the signature logs include the author’s credentials, but a claim will not be denied for missing credentials. Signature logs shall be considered regardless of the date they were created.
Attestation statements must be signed and dated by the author of the medical record entry and must contain sufficient information to identify the beneficiary. Attestation statements are not relevant if there is no associated medical record entry. Reviewers shall not consider attestation statements from someone other than the author of the medical record entry in question (even from physicians in the same group). Attestations shall be considered regardless of the date they were created, except in those cases where the regulations or policy indicate that a signature must be in place prior to a given event or a given date. An attestation can be used to clarify the identity associated with an illegible signature but cannot be used to “backdate” a plan of care.
The following is a sample attestation statement from the PIM. At this time, CMS does not require a certain form or format for attestation. Once the Office of Management and Budget (OMB) assigns an OMB Paperwork Reduction Act number to this attestation process, a certain form/format will be mandatory.
“I, _____[print 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 _____[insert provider credentials, e.g., M.D.]___ when I treated/diagnosed the above listed Medicare beneficiary. I do hearby 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.”
In cases of illegible signatures or signatures missing from documentation other than orders, the provider may submit an attestation statement or signature log with the medical record submitted for review. If there is an illegible signature or signature missing from documentation other than an order and no attestation or signature log is submitted, the reviewer shall contact the provider and ask if they would like to submit an attestation statement or signature log within 20 calendar days.
Signature Dating Requirements - For medical review purposes, if the relevant regulation, NCD, LCD and other CMS manuals are silent on whether the signature must be dated, the reviewer shall review to ensure that the documentation contains enough information for the reviewer to determine the date on which the service was performed/ ordered.
The transmittal also includes information on e-prescribing.
The transmittal was published March 16, 2010 with an effective date of March 1, 2010 and an implementation date of April 16, 2010. All signature requirements in this Change Request (CR) are effective for CERT reviews retroactively for the November 2010 report period. All signatures requirements for ACs, MACs, PSC, and ZPICs are applicable for reviews conducted on or after 30 days after the issuance of the CR.
See the transmittal at the link above or MLN Matters Article MM6698 for more information.