Two recent publications issued by CMS clearly indicate that the organization is tightening its requirements for the documentation required to support medical necessity and mandated signatures on prescriptions and orders for services.

The first publication is the "Improper Medicare Fee for Service Payments Report of November 2009." This report details the type and percentage of errors found in claims as determined by reviews performed under the CERT (Comprehensive Error Rate Testing) program. Page 9 of this document describes changes in what is acceptable and not acceptable for documentation to support the medical necessity of services provided.

Impact of the More Stringent Review Criteria

The more stringent review criteria for review of claims selected for the November 2009 report resulted in increases in error rates due to:

Records from the treating physician not submitted or incomplete

In the past, CERT would review available documentation, including physician orders, supplier documentation, and patient billing history, then apply clinical review judgment. Now, CERT requires medical records from the treating physician and does not review other available documentation or apply clinical review judgment.

Missing evidence of the treating physician's intent to order diagnostic tests

In the past, CERT would consider an unsigned requisition or physicians' signatures on test results. Now, CERT requires evidence of the treating physician's intent to order tests, including signed orders and/or progress notes.

Medical records from the treating physician did not substantiate what was billed

Again, in the past, CERT would review available documentation, including physician orders, supplier documentation, and patient billing history, then apply clinical review judgment. Now, CERT requires medical records from the treating physician and does not review other available documentation or apply clinical review judgment.

Missing or illegible signatures on medical record documentation

In the past, CERT would apply clinical review judgment in considering medical record entries with missing or illegible signatures. Now, CERT disallows entries if a signature is missing or illegible.

CERT Contractors Advised

CMS has instructed CERT contractors to follow the letter of the law in determining whether a claim has been billed properly and if there is sufficient documentation present to support the need for services. Thus, each claim must stand alone and be supported by documentation clearly showing the intent of the ordering physician and the reasons for ordering the service(s) for that episode of care, with orders that are complete and signed.

Further details related to signatures were published in Transmittal 327 of the Medicare Program Integrity Manual (100-08), released on March 16, 2010. The signature guidelines apply to reviews conducted by Medicare Administrative Contractors (MACs), CERT Contractors and Recovery Audit Contractors (RACs).

No Rubber Stamping

Medicare requires that services provided or ordered be authenticated by the author. The method used for authentication may be a handwritten or electronic signature. Rubber-stamp signatures are not acceptable.

Exceptions are made for certifications of terminal illness for hospice care and orders for clinical diagnostic tests. However, if there is an unsigned order for a clinical diagnostic test, there must be documentation by the physician, such as a progress note, that shows that the physician intended for the test to be performed. This documentation must be authenticated.

CMS states that providers should not add late signatures to the medical record (beyond the short delay that occurs during the transcription process), but instead use the signature authentication process. This process requires the author of the order to sign an attestation that he/she is the originator of the order, and does not allow for anyone but the ordering/treating physician to make the attestation. While there is currently no specified format or language for the attestation, a suggestion is included in the transmittal.

Signatures must be complete and legible. If a signature is illegible, there must be a typed or printed name next to the signature. Initials are not acceptable as signatures without further documentation (attestation, signature log, typed or printed name next to the initials, etc.)