Specifically, CERT reported an increase in improper payments and in the national fee-for-service (FFS) paid claims error rate (PCER) from its November 2008 report. According to the 2009 report, these increases can be traced back to five changes (listed below) made to the review methodology approved by the Department of Health & Human Services Office of Inspector General (OIG).
- Consolidation of the Hospital Payment Monitoring Program (HPMP) and CERT, which increased the error rate for inpatient hospital claims.
- Strict adherence to documentation requirements outlined by policy;
- Disallowance of supplier documentation;
- Removal of billing history as a valid source of information; and
- Strict enforcement of signature requirements.
This last item is of greatest importance since, before the November 2009 report release, CERT contractors did not deny claims for missing signatures. However, as described later in this article, parts of this policy have changed, and the reason for that boils down to one factor: loss of Medicare payments.
Between the issuance of the November 2008 and November 2009 CERT report, the national PCER increased from 3.7 percent ($10.2 billion) to 7.8 percent ($24.1 billion).
After an OIG consultation on the above factor, CMS issued Transmittal 327 (http://www.cms.gov/transmittals/downloads/R327PI.pdf), which covers signature (both handwritten and electronic) guidelines for medical review, to inform its contractors to strictly adhere to the Medicare policy requiring legible signatures.
This transmittal also provides guidelines on the topic for the following healthcare providers: physicians, non-physician practitioners, suppliers submitting claims to Medicare fiscal intermediaries (FIs), Part A/B Medicare administrative contractors (A/B MACs), carriers, regional home health intermediaries (RHHIs) and/or durable medical equipment MACs (DME MACs).
These revised and new signature requirements apply to medical reviews conducted on or after the implementation date of April 16, 2010. CMS noted that all signature requirements are effective retroactively for the November 2010 report period, which includes all 2009 discharge and service dates.
Contractors may request any information they deem necessary to make a prepayment or postpayment claim review determination. This includes any documentation submitted with the claims as well as documentation solicited from the primary provider and its third-party providers. Contractors performing medical reviews (automated, routine or complex) may request the unsolicited supporting documentation accompanying the claim, but are not required to do so.
However, there are two exceptions to this rule. Contractors may deny without reviewing the attached or simultaneously submitted documentation under two circumstances:
- When policies (statutes, regulations, national coverage determinations [NCDs] and local coverage determinations [LCDs]) are clear and can serve as the basis for denial; and
- In instances of medical impossibility.
Medicare requires that services ordered and provided be authenticated by the author through a handwritten or electronic signature. Stamp signatures are definitely not acceptable. If there are reasons for denial that are unrelated to signature requirements, the reviewer won't proceed to signature authentication.
As with many things related to Medicare, there are exceptions to the signature requirement rule, listed below:
- Facsimiles of the original written or electronic signatures are acceptable for the certifications of terminal illness for hospice.
- Orders for clinical diagnostic tests are not required to be signed.3 However, documentation of intent (e.g., progress note) from the treating physician must exist, and it must be authenticated.
(1) The November 2009 CERT Report can be found at www.cms.hhs.gov/CERT
- A CMS regulation (e.g. NCD, LCD or Medicare manual) that includes specific signature requirements takes precedence over the guidelines in Transmittal 327. Providers should not add late signatures to the medical record (beyond the short delay that occurs during the transcription process), but instead may use the signature authentication process described below.
- Also, contractors may add language in their additional documentation requests (ADRs) directing billing providers to contact another entity to obtain the signed version of a document. For example, a hospital discharge summary in the physician's office may not be signed, while the same version of the hospital discharge summary in the hospital is signed and dated. Billing providers are encouraged to review their documentation for signatures before sending records to the contractor reviewer, or attach a signature log or attestation statement.
If at any time the contractor suspects evidence of fraud, which could include a pattern of missing/illegible signatures, this will result in a referral to the PSC/ZPIC.
Alternatives for Legible Signatures
If the signature is illegible, contractors will review evidence in a signature log or attestation statement to identify the author of the medical record entry. If the signature is missing from an order, contractors shall disregard the order during the claim review. If the signature is missing from any other medical documentation, a signature attestation from the author of the entry will be accepted.
As listed below, there are several scenarios that constitute compliance with this rule. Specifically:
- Legible full signature;
- Legible first initial and last name;
- Illegible signature over a typed or printed name;
- Illegible signature accompanied by letterhead, addressograph or other information on the page that indicates the author's identify;
- Illegible signature with documentation that is accompanied by a signature log or an attestation statement;
- Initials over a typed or printed name;
- Initials not over a typed/printed name, but accompanied by a signature log or an attestation statement;
- Unsigned handwritten note with other signed entries on the same page, writtenin the same handwriting.
Signature Log. As part of a patient's medical record, providers may submit a signature log that includes the author's typed or printed name associated with initials or an illegible signature. CMS recommends that the log include the provider's credentials, but failing to include them does not constitute a reason for denial.
Signature Attestation. The documentation may include the fact that a provider submitted an attestation statement (note that there is no required format for this statement). To be considered valid for Medicare medical-review purposes, the author must sign and date this statement, and it must contain sufficient information to identify the beneficiary. Contractors will not consider attestation statements from anyone (such as a partner in the same physician group) other than the author of the medical record entry (or attestation). Attestation statements also won't be considered when there is no associated medical record entry.
In the transmittal, CMS provided the following as an example of an acceptable attestation statement:
"I, [print full name of the physician/practitioner], hereby attest that the medical 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 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."
Noncompliance with Requirements
The contractor may contact the billing provider and ask for a signature log or attestation statement within 20 calendar days. This time frame begins when the contractor makes a phone call or at the postmark time on a sent letter. Note that no such contact will be made when the claims should be denied for reasons unrelated to the signature requirement.
The following circumstances identify noncompliance with the signature requirement:
- Illegible signature not over a typed/printed name and not on letterhead, with no signature log or attestation statement accompanying documentation;
- Initials not over a typed/printed name and not accompanied by a signature log or attestation statement;
- Unsigned, typed note with provider's typed name;
- Unsigned, typed note without provider's typed/printed name;
- Unsigned handwritten note (the only entry on the page); and
- Statement such as "signature on file."
Dating the Signature
If a relevant regulation (NCD, LCD, or other CMS manual) is silent on whether a signature must be dated, the contractor shall review the documentation to ensure that it contains enough information to determine the date on which the service was performed.For example, consider that a physician performs an evaluation and management (E&M) review and dates the documentation as 10/04/09. The hospital sends an undated E&M progress note to the contractor for review. If the physician's E&M note includes the date of 10/4/09 and the note following the E&M note is dated 10/4/09, the contractor may conclude that the hospital's E&M progress note also occurred on 10/4/09.
Beware Electronic Systems
As CMS points out in the transmittal, providers using electronic systems need to recognize that there is a potential for misuse or abuse with alternate signature methods. For example, providers need a system and software products that are protected against modification, and they should apply administrative procedures that correspond to the above standards.
CMS also advises the following: "the individual whose name is on the alternate signature method and the provider bears the responsibility for the authenticity of the information being attested to. Physicians are encouraged to check with their attorneys and malpractice insurers in regard to the use of alternative signature methods."
2See Title 42, Code of Federal Regulations (CFR), Section 410.32 at http://ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecfr&tpl=%2Findex.tpl and Chapter 15, Section 80.6.1 of the Medicare Benefit Policy Manual at http://www.cms.gov/manuals/Downloads/bp102c15.pdf.
About the Author
Carol Spencer, RHIA, CCS, CHDA is a senior healthcare consultant with Medical Learning, Inc. (MedLearn®) in St. Paul, Minn. MedLearn is a nationally recognized expert in healthcare compliance and reimbursement. Founded in 1991, MedLearn delivers actionable answers that equip healthcare organizations with coding, chargemaster, reimbursement management and RAC solutions.
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